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:
Date(s) of Absence:
Symptoms: Nausea Fever Productive Cough Rash Sore Throat
  Influenza Flu-like Symptoms Vomiting Diarrhea
Reported By:
Did absent employee recently receive a COVID Vaccination?
Vaccination Date: