Employee Assistance Program Log
Log your participation and activities in the Employee Assistance Program.
Employee Full Name
*
First Name
Last Name
Department
*
Please Select
Human Resources
Finance
Operations
IT
Marketing
Other
Date of Assistance
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Assistance Received
*
Counseling
Referral
Crisis Intervention
Wellness Workshop
Other
Brief Description of Assistance or Notes
Email Address (for follow-up, if needed)
example@example.com
Submit Log
Should be Empty: