This form needs to be completed by the employee or department manager and submitted within 3 days of reported illness or injury. By clicking Submit the completed form will be emailed to the Infection Control Nurse.

Employee Name    

Department

Symptom or reason for staying home:

Disposition: Pick One Stayed Home Sent Home Allowed to work Hospitilized

Dates of absence:

Procedure or treatment

Form completed by Employee Department Manager

Comments:

Email of form submitter: