Sickness Absence History Form
Please complete this form to document your sickness-related absence. All information will be kept confidential and used for absence management purposes.
Full Name
*
First Name
Last Name
Department or Position
*
Contact Email Address
*
example@example.com
Absence Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Absence End Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Absence
*
Please Select
Flu or Cold
Injury
Chronic Condition
Medical Appointment
Other
Upload Medical Certificate or Supporting Document (if available)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Additional Comments (optional)
Submit Absence Record
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