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Employee Illness Report

Posted September 6, 2017 by Nathan Moser

Employee Illness Report

"*" indicates required fields

Employee Name

First Last

Department*

Person Completing the Report

First Last

Date of Report

Date of Illness (Absence)

Absence Due to (Check Box If Applicable)

Employee Illness

Absent Due to Ill Child or Family Member

Absent Due to Weather

Absent Due to Other

If you indicated "other", please explain:

Date and Time of First Symptoms

Symptoms (Check all the apply)

Fever

Respiratory

Sore Throat with fever

Vomiting

Diarrhea

Nausea

Headache

Jaundice

Lesions (or exposed skin)

Persistent Cough

Temperature

Other

If you indicated "other" in symptoms, please explain:

Did the employee see a healthcare provider?

Date employee expects to return to work

Is the employee assigned to food handling?

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This institution is an equal opportunity provider and employer. If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at program.intake@usda.gov.

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515 Pacific Avenue Audubon, IA 50025

Phone: (712) 563-2611

Employee Illness Report

Employee Illness Report

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