Report an Employee Absence

Please fill out this form to report employee absences due to illness. The results of this form will be sent to Employee Health.

 

Name of Absent Employee:
Phone:
Department:
Date(s) of Absence:
Symptoms: Nausea Fever Productive Cough Rash Sore Throat
  Influenza Flu-like Symptoms Vomiting Diarrhea
Reported By:
Comments: