ABSENCE REPORT
Routing
This Report is for a
Last
First
Middle
Employee Payroll #
Telephone
Format: (000) 000-0000.
Shift
Absence Start Date
/
Month
/
Day
Year
Date
Absence End Date
/
Month
/
Day
Year
Date
Absent Reported By
Telephone
Format: (000) 000-0000.
Was Notification of Absence Received in a Timely Fashion?
Please Select
Yes
No
If Medically Treated, Was a Doctor Seen?
Please Select
Yes
No
If the Absence Exceeded Three Days, Was a Physician Certification Requested?
Please Select
Yes
No
Change(s) for Current Employee
Reason for Absence
Reason for absence as explained by employee
List follow-up action, if any, scheduled with the employee and list date :
Date
/
Month
/
Day
Year
Date
Supervisor Comments
Date
/
Month
/
Day
Year
Date
Supervisor designated Manager Signature
Date
/
Month
/
Day
Year
Date
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