Employee Call Out Form
(24 hours notice is preferred)
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 Name
Last Name
Employee ID
*
e.g., 1234AB
Phone Number
*
918-000-000
Email
example@example.com
Member Category
*
Please Select
HomeAlign
Medicaid
Veteran
Private Pay
Vet Assist
Reason for Call Out (check all that apply)
Medical Appointment for myself
Reason for Call Out (please describe the reason as briefly as possible)
*
Will you attempt to make up the time or should we move to have your shift covered?
*
Yes
No
If you choose to make up the time, when would you be available to do so?
Please attach a medical report from your doctor if you are calling out for more than 3 days due to the illness
Browse Files
Please attach your medical report.
Cancel
of
Call Out Member Name (Shift 1)
*
First Name
Last Name
Call Out Date (Shift 1)
*
-
Month
-
Day
Year
Date
Call Out Time (Shift 1)
*
e.g. from 12:00pm - 4:00pm = 4 hours.
Call Out Member Name (Shift 2)
First Name
Last Name
Call Out Date (Shift 2)
-
Month
-
Day
Year
Date
Call Out Time (Shift 2)
e.g. from 12:00pm - 4:00pm = 4 hours.
Call Out Member Name (Shift 3)
First Name
Last Name
Call Out Date (Shift 3)
-
Month
-
Day
Year
Date
Call Out Time (Shift 3)
e.g. from 12:00pm - 4:00pm = 4 hours.
Submit
Should be Empty: