Sickness Leave Form
How many TOTAL Hours did Employee miss?
Start Date
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Month
-
Day
Year
Date
End Date
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Month
-
Day
Year
Date
How many working days are you submitting for sickness leave?
Employee Name
First Name
Last Name
Store #
Reason for Sickness Leave
Reminder: If the sick leave is more than 3 days, a fit-to-work certificate from the doctor is needed in order to get back to work.
By signing below, I confirmed that all information in this form is true and accurate.
Employee's Signature
Date Signed
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Month
-
Day
Year
Date
Supervisor Name
First Name
Last Name
Supervisor's Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
Print Form
Should be Empty: