From Dnr1225 - Employee Call In/off Form

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ODNR Employee Call In/Off Form
Employee Name: _______________________________ Div./Office ____________________________
Time of Call: _____________ Work Schedule: _____________ Date of Absence: ________________
_____ Illness
Family Illness: _____ Spouse
Reason:
_____ Bereavement
_____Child
_____Accident
_____Parent
_____ Other
_____Other (Specify)
____________________
Type of Leave: _____ Sick Leave
_____ Vacation (Emergency)
_____ Vacation (in Lieu of Sick Leave)
_____ Personal (Emergency)
_____ Personal (in Lieu of Sick Leave)
_____ Other _______________
Comments:___________________________________________________________________________
____________________________________________________________________________________
1. How long will you be absent? _____________________________________________________
2. Will you be hospitalized? _________ In-Patient __________ Out-Patient ___________________
3. Have you seen a doctor? __________ Are you going to see a doctor? ______________________
4. Are you under continuing care or treatment? __________ If yes, for how long? ______________
5. If your absence is due to the illness of a family member, what care are you providing?
______________________________________________________________________________
6. Have you requested or been informed this illness /condition qualifies for either:
 FMLA – Family Medical Leave Act
 ADA – Americans with Disability Act
7. Phone number where you can be contacted: ___________________________________________
Call taken by: ______________________________________________________________________
Supervisor Section:
Did you notify the employee that this leave qualifies as FMLA and will be credited toward his/her 12
week yearly entitlement?
 Yes  No
Date of Notification ________________________
_________________________________________
_______________________________________
Supervisor Acknowledgement
Date
Follow Up Contact Date (If Necessary)
Note: the employee should not be asked to disclose confidential medical information (i.e., diagnosis or
prognosis). He/she need only indicate an excusable medical condition. Human resources may follow-up
to determine whether that condition would constitute FMLA eligibility.
* This form should be attached to the employee’s Request for Leave Form.
From DNR1225 11/10

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