Staff Absence Form

Name *

Date completed: *

Dates(s) of absence: *

If caring for dependant – your expected date back to work (if known):

If yourself – your expected date back to work (if known):

Reasons for Absence - General Sickness

Reasons for Absence - Possible Covid Symptoms (Self)

• Fever
• Loss of Taste/Smell
• Cough

Other Information

Reasons for Absence - Possible Covid Symptoms (Family Member)

• Fever
• Loss of Taste/Smell
• Cough

Other Information

Test Needed? *

• Yes
• No

Booked self-test? *

• Yes
• No

Date of self-test (If Applicable)

Booked school test? *

• Yes
• No

Date of school test (If Applicable)

Test Results

• Positive
• Negative

Date of Test Result

Submit