Employee Name:
Department:
Was this employee working at the time they brought this to your attention? Yes No
Time of Call: (AM or PM)
Symptoms Vomiting Diarrhea
Specific Symptoms:
In detail, what exactly is wrong with them:
If this employee has either vomiting or diarrhea, they may not return to work for 24 to 72 hours according to the Saginaw Department of Public Health.
Please attach any doctor's notes or paperwork below.
YOUR SIGNATURE INDICATES ONLY THAT YOU HAVE READ AND UNDERSTAND THE ABOVE.
Employee Signature (Please type full name):
Supervisor Signature (Please type full name):
