Report of Staff Illness

Report of Staff Illness
This form must be completed for any employee that calls out sick or sent home sick for any reason. This includes, but not limited to:
1. Employees working and sent home sick
2. Employee calls out sick but worked within the last 48 hours in any work location
3. Employees that worked in the last week.
These are important to ensure illness is not spread within our work locations. This form is essential for tracking employee illness within Springbrook. This form will be automatically routed to appropriate departments.
Staff ID #:
Staff Name:

First NameLast Name
Staff Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Staff Phone Number:

Area CodePhone Number
Staff Alternate Phone Number 1

Area CodePhone Number
Staff Alternate Phone Number 2

Area CodePhone Number
Date Staff reported illness:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Did the staff come into work or call out
When was the last date the staff worked?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Shift Hours Staff Worked:
Division
Primary Work Location
Did the employee work or enter multiple Springbrook locations?
If yes, please list them all below:
Symptoms

Other
Manager ID #:
Manager Name:

First NameLast Name
Manager email:
example@example.com
Number of staff in home:
Number of individuals in home:
Manager Work Location
Did you call the MOC/AOC?
Details/Notes:
Next Steps:
1. Send all relevant documentation (i.e sick notes) to HR at humanresources@springbrookny.org
2. Communicate all updates to HR regarding return to work or any relevant information.
Should be Empty: