Choice Home Care - EVV Time Adjustment form

Sick Pay Form
Instructions
If you are calling out sick for a scheduled shift for any reason, please complete the information below in full and one of our HR Associates may contact you if we have any questions. Some fields and responses are optional.
Employee Name*

First NameLast Name
Employee ID*
Employee ID (You can find on your Pay Stub or by clicking on "Account" in Choice EVV app)
Phone Number*

Area CodePhone Number
Employee Email*
example@example.com
Reason for use of accrued Sick Pay (check all that apply)*

Medical Appointment for myselfI am too ill to work - Sore ThroatI am too ill to work - CoughI am too ill to work - Stomach AcheI am too ill to work - AllergiesI am too ill to work - MigraineI am too ill to work - InjuryOther
Covid-19 Special Considerations

Possible exposure to ME for Covid-19, Self-quarantinedPossible exposure of a Family I support to Covid-19, self quarantinedDiagnosis of a Family I support to Covid-19I have been diagnosed with Covid-19
Client Name 1*

First NameLast Name
Missed Schedule and Comments
Must list dates and hours scheduled and reason care was cancelled.
Client Name 2

First NameLast Name
Missed Schedule and Comments
Must list dates and hours scheduled and reason care was cancelled.
Client Name 3

First NameLast Name
Missed Schedule and Comments
Must list dates and hours scheduled and reason care was cancelled.
Is there something you need to send with this? (Optional)

Upload a File
Hover to get more information Cancelof
Employee Signature*

Clear
Should be Empty:

Sick Pay Form