EMPLOYEE CLINIC ATTENDANCE RECORD

Name of employee ________________ Mine No. ________________

Department ______________________ Section ________________

Job Title _____________________ Shift (day/night_________________

Date of Attendance ______________

Time left work______________________ Supervisor’s signature___________

Time left Clinic _____________________

Injury/Illness _____________________

Duty type _____________________ Review date ________________

Clinic comments____________________

Clinic official’s signature_____________

EMPLOYEE CLINIC ATTENDANCE RECORD

Name of employee ________________ Mine No. ________________

Department ______________________ Section ________________

Job Title _____________________ Shift (day/night_________________

Date of Attendance ______________

Time left work______________________ Supervisor’s signature___________

Time left Clinic _____________________

Injury/Illness _____________________

Duty type _____________________ Review date ________________

Clinic comments____________________

Clinic official’s signature_____________