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UIC/ Department of Germanic Studies

German Language Program


Director: Dr. Susanne Rott, UH 1516
Excused Absence Request Form
Instructions: The student should fill out the top portion of this form and submit it with appropriate
documentation to his/her instructor. All information must be filled out or the form will be returned to the
student. The instructor will then submit the form to the Language Program Director. Once a decision has been
made, the instructor will inform the student and keep the form on file.
Student name:

SS#:

____________
Course:

Call #:

__________________
Instructor: _________________________________

Date of absence: ____________________________

Original exam date and lesson(s) covered: __________________________

Makeup date: ________________

Reason for absence: _________________________________________________________________________


_________________________________________________________________________________________
_
_________________________________________________________________________________________
_
Describe documentation attached:
______
Do not write below this line.
------------------------------------------------------------------------------------------------------------------------------------

Department of Germanic Studies use only


Date form submitted to instructor: ___________________________________________
Excused
Signature:

Not excused

More information requested:


Date:

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