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(If this is not a self-referral, please ensure the employee is aware of this referral.)

If sick leave or short-term disability

If absence exceeds 5 days

Employee Information

Can be found on your paycheque

USask Information

Additional Information

If you have medical notes to accompany this form, please email them to   wellnessresources@usask.ca

If you have any questions please contact Wellness Resources

(306) 966-4580
 wellnessresources@usask.ca