Employee Medical Absence History Form
Submit your medical absence details and return-to-work information for HR review.
Employee Full Name
*
First Name
Last Name
Employee Department/Team
*
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
Illness
Injury
Medical Appointment
Family Medical Emergency
Other
Total Number of Absence Days
*
Did you visit a doctor or receive treatment during this absence?
*
Yes
No
Upload Supporting Medical Documentation (if available)
Upload a File
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of
Are there any recurring patterns to your medical absences?
List any work restrictions or accommodations needed upon your return
Submit
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