Optim’action Notice of Absence

The fields identified by a star (*) are mandatory.

Employee

Associated Files (medical certificate, etc.)

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The sum of all files must be lower than 30 MB

First Name *

Last Name *

Home Phone *

Birthdate

Position

Date stopped working

Task Description

Employer

Company *

Contact First Name *

Contact Last Name *

Phone *

Fax

E-mail *

Reason / diagnosis given by employee *

Additional Informations

Diagnosis

Prognosis

Treatment

Expected date of return to work

Additional information

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