Employee Illness Report
To comply with Joint Commission standards, this form must be completed when there has been an illness of three (3) days or more due to a medical condition.
Who is completing this form?
The employee
The employee's director
Employee name:
*
First Name
Last Name
Employee ID:
*
Date absence started:
/
Month
/
Day
Year
Date
Date absence ended:
-
Month
-
Day
Year
Date
Department Number:
*
Department Name:
*
The employee's assigned duties are in a patient care area:
*
Yes
No
The employee's illness includes the following:
*
Cold symptoms
Flu symptoms
Pink eye
Fever
Cold sores
Rash
Boils
Infected cut or draining wound
Rash location:
Number of days I've had a rash:
Boil location:
Wound location:
The employee was prescribed antibiotics:
*
Yes
No
The employee's symptoms are still present:
*
Yes
No
Describe current symptoms:
The employee has consulted a healthcare provider (physician, PA, ARNP):
*
Yes
No
Department Director Review
This employee has not consulted a physician and still has symptoms. I have instructed him/her to see a healthcare provider (physician, PA, ARNP) for clearance to return to work.
This employee is under a healthcare provider's care and has a note releasing him/her to full-duty work.
This employee has no symptoms and is able to return to work.
Signature
*
Clear
Please verify that you are human
*
Submit
Should be Empty: