Report Staff Absence

Report Staff Absence for Illness

Due to reporting requirements associated with the COVID-19 pandemic, this form is staff member use when reporting absences due to illness.  To report non-illness related absences, please follow your normal procedure.

Please fill out the following form, but remember to also notify your supervisor directly of your absence.  


1.  Employee Name:

2.  School/Department:

3.  Date of Absence (mm/dd/yy):

4.  Have your symptoms lasted more than 24 hours?

*NOTE:  If your illness symptoms have completely resolved within 24 hours of onset, then you can return to work on your next scheduled work day.  If symptoms persist past 24 hours, please submit another absence form for each day you'll be absent and a member of the COVID Response Team will contact you with a return to work plan.

5.  Date you were last at work (mm/dd/yy):

6.  Supervisor's name:

7. Your best contact phone number (xxx-xxx-xxxx):

8.  Email address (that you have access to while you're absent):

9.  What date did you first show illness symptoms (mm/dd/yyyy) (Please enter a Date, not yesterday/today/last week, etc.):

10.  What time did you first show illness symptoms on the date listed in Question 9:

11.  Please select the symptoms you have been experiencing (hold the Control Key to check all that apply):

12.  If you selected Other in Question 11, please explain:
 

13.  What is your temperature:

14.  Did you have a known exposure or close contact to a person diagnosed COVID-positive?

15.  Do you plan to contact your healthcare provider and/or get a PCR COVID test?

16.  Please list any co-workers with whom you've been in "Close Contact" ("Close Contact" is defined as 'contact' less than 6 feet apart for 15 minutes or longer) within the past 48 hours or with whom you share an office or classroom (Please list any who would apply - if none, please write none):
*Note:  Co-workers listed here are not necessarily required to quarantine.  A COVID Response Team member will notify any staff members who need to quarantine.


Thank you for submitting this form to record your absence.  Please be sure to also notify your supervisor and put in a sub request if that is normal for your position! After you submit this form, you will  be redirected to a page with further instructions - please read those instructions carefully!
 



Security Measure