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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

If you have any questions please contact Wellness Resources

(306) 966-4580

Please ensure that you are not submitting confidential or sensitive information.