Absence Details

First date of absence
Final date of absence
Total number of days absent:
Please detail the reason for absence choosing from the list of absences:

Did you receive medical treatment during your absence?

If yes, please state where and when below


Please enter time and date:

Is your absence as a result of an occupation injury

Employee's Signature
Please sign to confirm all details above:
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.