FS number

Enter job number

Was this originally an all day, T1 (am) or T2 (pm) visit?

Did you attend all day, T1 (am) or T2 (pm)?

What was the visit date and time attended?

Please give the reason for attending out of eta.

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.