Staff - Absence-Sickness Certification Form

1. ABSENCES: This form is to be completed and submitted PRIOR to any absence from work.
1. SICKNESS: In the case of last minute sickness or injury, the form needs to be submitted as soon as possible.

2. EMAIL PROGRAM MANAGER: in addition to submitting this form ... if you are requesting an ''Absence from Shift'' advising YOU will be looking to find someone to cover your shift. [email protected]

3. EMERGENCIES: where you are giving less than 24 hours’ notice, you MUST CALL the Program Manager on 0402-739-827

Staff - Absence/Sickness Certification Form

1. This form is to be completed on your return to work following any period of Sickness or Absence from work.

* Indicates required field

I submit this form for the following reason: *

Absence Sickness

NAME: *

First

Last

Email *

Phone Number *

Sickness or Absence BEGINS on DATE: *

Sickness or Absence BEGINS on DAY: *

Sickness or Absence BEGINS from TIME AM/PM: *

Sickness or Absence FINISHED on DATE: *

Sickness or Absence FINISHED on DAY: *

Expected date of return to work from Sickness or Absence: *

Please provide details of the Sickness or Absence *

Did you consult a Doctor *

YES NO

If YES, please give details of the DOCTOR NAME, ADDRESS, DATE OF VISIT, TREATMENT & ANY CURRENT TREATMENT *

If NO, Please state the reason why you did not see a Doctor *

H2O OFFICE USE ONLY: *

- Approved / Not Approved - Program Manager Advised - Recorded on Personnel file

Submit