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.
Group of CMH Employees


Name of Absent Employee:
Long Term Care Facility:

Date(s) of Absence:
Symptoms: Nausea Fever Cough Rash Sore Throat
  Nasal Congestion Runny Nose Vomiting Diarrhea
Diagnosed With:

Reported By:
Did absent employee recently receive a COVID Vaccination?
Vaccination Date: