Employee Health Support Plan Form
Submit your details to help us assess and provide appropriate health support at work.
Employee Full Name
*
First Name
Last Name
Employee Email Address
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Department
*
Please Select
Human Resources
Finance
Operations
IT
Sales
Marketing
Other
Job Title
*
Please briefly describe your current health concern(s) or condition(s) that require support.
*
What type of support or accommodation are you seeking? (Select all that apply)
*
Flexible work schedule
Ergonomic equipment or workstation adjustment
Remote work options
Modified duties or workload
Access to counseling or health resources
Other
Please provide any relevant medical history or previous accommodations (optional)
Emergency Contact Name and Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
By submitting this form, I confirm that the information provided is accurate to the best of my knowledge. I consent to the use and limited sharing of my health information for the purpose of workplace support planning.
*
Submit Support Request
Submit Support Request
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