Not Feeling Well?
Please Fill Out Below
Employee Name
Date
Reasons for Absence
Symptoms:
Severity of Symptoms
1 (Mild)
2
3
4
5
6
7
8
9
10 (Severe)
Do you have a doctor's note or medical documentation related to your absence?
Yes
No
If Yes, Please attach here
Expected Return?
Alternate Contact:
Alternate Contact Number:
Work Responsibilities:
Follow-up Communication:
Additional Comments:
I understand that by submitting my sick day anytime after my shift has started may result in a tardiness reprimand?
Yes, I understand.
I understand that this will count towards (1) of my (7) sick days of the Year.
Yes, I understand.
Reprimands are as follow; • Requesting sick time off after my initial start time (Verbal Warning | Write up | Dismissal) • More than 7 days sick time in a year (Verbal Warning | Write up | Dismissal)
Yes, I understand.
I understand that calling in sick is different than; showing up and going home sick. This will not be counted as a sick day.
Yes, I understand.
I understand that if I have another employee who is off the same day as my sick day, and they come in to cover my shift I will not have a sick day taken from my total sick days for the year.
Yes, I understand
Have you contacted a Coworker to cover your shift?
Yes
No
If so which coworker did you contact?
If applicable; Are you able to switch days off with your current sick day?
Yes
No
I am switching days off with another employee.
Which day would you work instead?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
None of the above
Submit