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:
Long Term Care Facility:	Ash Grove HCF Butterfield Residential Care Center Citizens Memorial HCF Colonial Springs HCC Community Springs HCF Lake Stockton HCF Parkview HCF Not an LTC Employee
Date(s) of Absence:
Symptoms:	Nausea Fever Cough Rash Sore Throat
	Nasal Congestion Runny Nose Vomiting Diarrhea
Diagnosed With:	Influenza COVID
Reported By:
Did absent employee recently receive a COVID Vaccination?	Yes No
Vaccination Date:
Comments:

Let's keep in touch

Hospital 417-326-6000

Infocenter 417-328-6010, or 1-888-328-6010

1500 North Oakland, Bolivar, Missouri 65613

Hospital 417-326-6000

Infocenter 417-328-6010, or 1-888-328-6010

1500 North Oakland, Bolivar, Missouri 65613

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:
Long Term Care Facility:	Ash Grove HCF Butterfield Residential Care Center Citizens Memorial HCF Colonial Springs HCC Community Springs HCF Lake Stockton HCF Parkview HCF Not an LTC Employee
Date(s) of Absence:
Symptoms:	Nausea Fever Cough Rash Sore Throat
	Nasal Congestion Runny Nose Vomiting Diarrhea
Diagnosed With:	Influenza COVID
Reported By:
Did absent employee recently receive a COVID Vaccination?	Yes No
Vaccination Date:
Comments:

Let's Keep In Touch