COVID-19 Self Quarantine Employee Leave Form

COVID-19
Self Quarantine Employee Leave Form
Request leave for...*
First NameLast Name
Employee status
BenefitedNon-benefited
Phone (employee)*
Area CodePhone Number
Email (employee)*
example@example.com
Date the leave starts*
MonthDayYear
Date
Employee department*
Position/Title of the employee*
Number of hours the employee is scheduled to work per week.*
Supervisor's Name*
First NameLast Name
Supervisor's phone number*
Area CodePhone Number
Any special circumstances HR may need to know.
Supervisor's please contact Kim Hall 801-804-4504 or Tara Silver 801-804-4589 as soon as the employee's condition changes. (ie. becomes sick or their situation changes)
Should be Empty: