Termination During Medical Leave Report Form
Use this form to document and review a termination that occurred during an employee’s medical leave. Please provide all relevant details and references to supporting documentation.
Employee Name
*
First Name
Last Name
Employee Department
*
Type of Medical Leave
*
Please Select
Short-Term Medical Leave
Long-Term Medical Leave
Family and Medical Leave (FMLA)
Other
Date of Termination
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Termination
*
Decision Maker Name and Title
*
Method of Termination Notice
*
Please Select
In Person
Phone Call
Email
Letter
Other
Reference to Supporting Documentation (file names, locations, or IDs)
Summary of Follow-Up Actions or Notes
Submit Report
Should be Empty: