Sick Time Reporting Form
Name
*
First Name
Last Name
Email
*
example@example.com
Department
*
Shift Supervisor Full Name
*
Please write your current shifts supervisor above
Hospital Location
*
Please Select
Pipeline Health - Gardena
Pipeline Health - Coast Plaza
Pipeline Health - East LA
Pipeline Health - Community Park
Prime Healthcare
Are you missing a scheduled shift due to this illness?
*
Yes
No
If yes, list the date(s) and time(s) of scheduled shifts missed.
*
Type of Leave Requested
*
Sick Leave (Paid)
Sick Leave (Unpaid)
COVID-19 Related Leave
Other
If you selected "Other", please specify what type of leave you're requesting:
*
Date of Which Sick Leave Begins
*
/
Month
/
Day
Year
Date
Estimated Date of Return
*
/
Month
/
Day
Year
Date
General nature of the illness (optional):
Is this illness work-related or due to a workplace exposure?
*
Yes
No
Do you anticipate needing a medical clearance to return to work?
*
Yes
No
Not Sure
Will you be providing a doctor's note?:
*
Yes
No
Please Upload Doctors Note
*
Browse Files
Drag and drop files here
Choose a file
Please use your mobile device to take a picture of your doctor's note and upload it here.
Cancel
of
I certify that the above information is true and accurate to the best of my knowledge. I understand that falsifying information may result in disciplinary action. I agree to notify my agency and the HR team of any changes to my condition or return-to-work date.
*
Yes
Submit
Should be Empty: