| Updated On | [date-and-time] | Received Date | [Date] |
|---|---|---|---|
| Effective Date of Change | [Date] | Change Reason | [field-value] |
| Approval Requested | [True] | Approval Status | [Approved] |
| Status | [Active] | Updated By | [User Name] |
Medical Institution Temporary Absence Details
| Household Member | [field-value] |
|---|
| Absence Start Date | [Date] | Absence End Date | [Date] |
|---|
| Reason for Absence | [field-value] |
|---|
| Under Jurisdiction of Institution/Waiver Program | [True] |
|---|
Comments
| [Comments] |