Instructor Notification Request

"*" indicates required fields

Student Name*

First Last

Phone*

Email*

CSU ID*

Please do not include dashes.

Referral Source*

Please provide the name & relation (professor, friend, adviser, etc.)

Reason for Absence*

Bereavement

Medical

Legal

Other

Brief Explanation*

Full Name of Deceased*

Relationship*

Date of Passing*

Circumstances*

(Immediate grief, funeral, religious ceremony, etc.)

Expected Date Absent – Start*

MM slash DD slash YYYY

Expected Date Absent – End*

MM slash DD slash YYYY

File*

Max. file size: 31 MB.

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