Sick Leave Form

Purpose: This form is to be completed by employees to officially report an absence due to illness or injury. It also serves to collect necessary details including medical documentation if required by company policy.

Employee Information

Full Name: {fullName}
Employee ID: {employeeId}
Department: {department}
Supervisor: {supervisor}
Date of Submission: {submissionDate}

Sick Leave Details

Start Date of Leave: {startDate}
End Date of Leave: {endDate}
Total Days Away: {totalDays}
Type of Illness/Injury (optional): {illnessType}
Contact During Leave: {contactMethod}
Additional Notes: {additionalNotes}

Medical Certificate

{#hasMedicalCertificate}

Medical Certificate Provided: Yes

Issued By: {certifyingDoctor}
Medical Facility: {medicalFacility}
Date Issued: {certificateDate}
Additional Comments: {certificateNotes}

{/hasMedicalCertificate}

{^hasMedicalCertificate}

Medical Certificate Provided: No

{/hasMedicalCertificate}

Work Delegation

Please list any temporary task delegation, if applicable:

{#delegations}

• Delegated Task: {task}
  Assignee: {assignee}

{/delegations}

Approval

Employee Signature: ____________________________
Date: {employeeSignatureDate}

Manager/Supervisor Approval: ____________________
Date: {managerApprovalDate}