SICK PAY REQUEST FORM

Date:
Employee Name: Employee #:
Employee Start Date: Full Time Part Time
Approx. Date of Last Sick Pay Request:
BOOK ON / BOOK OFF TIMES
DATES FOR SCHEDULED SHIFT
SCHEDULED SHIFT # OF HOURS
OF SICK DAYS
(Military Time – 24hr clock)
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Name of Site:

PLEASE ATTACH DOCTOR’S NOTE

Doctor’s Note Provided: Yes No
If Doctor’s Note is not provided, please explain below:

(Employee’s Signature)

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