Notice of Prolonged Absence

* Member's First Name:

* Member's Last Name:

* Language Preference of Member:

EnglishFrench

Member's Email Address:

Member's Phone Number:

( ) -

Alternate Phone Number:

( ) -

Member’s Mailing Address:

* Date on which member last worked:

* School Board:

* Plan Number:

* Division Number:

School Name:

* Have you contacted the member to share information regarding the Early Intervention (EI) Program?:

YesNo

Comments (any applicable information your member has permitted you to share with the Early Intervention program):

By submitting this form, you agree to receive an email reply confirming your submission and understand that email is not a secure form of communication. As email security cannot be guaranteed due to possible third party interception or tampering, OTIP does not assume responsibility for the possible breach of the personal information you have submitted.

* Your First Name:

* Your Last Name:

* Email Address:

* Phone:

( ) -

* Role:

Union Representative
Plan Administrator
Other

If other, please specify:

Questions? Please send an email to earlyintervention@otip.com