Employee Illness Report Posted September 6, 2017 by Nathan Moser Employee Illness Report Employee Name First Last Department Person Completing the Report First Last Date of Report MM slash DD slash YYYY Date of Illness (Absence) MM slash DD slash YYYY Absence Due to (Check Box If Applicable) 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?YesNoDate employee expects to return to work MM slash DD slash YYYY Is the employee assigned to food handling?YesNo
