"Employee Call/Report-Off Form" - Ohio

Employee Call/Report-Off Form is a legal document that was released by the Ohio Department of Administrative Services - a government authority operating within Ohio.

Form Details:

  • Released on January 1, 2004;
  • The latest edition currently provided by the Ohio Department of Administrative Services;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Ohio Department of Administrative Services.

ADVERTISEMENT
ADVERTISEMENT

Download "Employee Call/Report-Off Form" - Ohio

448 times
Rate (4.4 / 5) 21 votes
EMPLOYEE CALL/REPORT-OFF FORM
PART 1
Questions and Statements Must Be Read As Written
Employee Name:
Time of Call:
Date of Absence:
Work Schedule:
Phone Number
(This Should be a number where the employee can be reached today for follow-up purposes as necessary)
REASONS FOR ABSENCE:
IF SICK LEAVE, IS REASON FOR:
Illness
Spouse
Bereavement
Self
Parent
Accident
Son/Daughter
Vacation
Other (Specify)
Other ________________________
Personal
(specify)
Comments:
If absence is for an illness for you or your family member, do you have a State Of Ohio Physician or Health Care
Yes
No
Provider Certification For The Family & Medical Leave (ADM 4260 ) for this condition?
Part 2
Part 2 is completed if the employee is using sick leave and does not have a certified ADM 4260 form for this condition.
The questions under Part 2 are asked and the form is completed by the employee's supervisor or designee.
How Long are you going to be absent?
Yes (In-patient)
No (Out-patient)
Will you or your family member be hospitalized?
Yes
No
Will you be applying for disability benefits?
Will you be applying for Workers' Compensation?
Yes
No
Will you or your family member see a medical professional for this absence?
Yes
No
Yes
No
Are you under continuing care or treatment for this condition?
If any of the questions were answered YES, please immediately forward this form to the
Office of Employee Services 30 E Broad St 40th Floor; Fax 728-4683
:
Call taken by
(Supervisor or Designee Department)
Date
Phone #
Supervisor's Signature
Date
Phone #
NOTE: The employee should not be asked to disclose confidential medical information (I.e., diagnosis or prognosis).
The Office of Employee Services may follow-up to determine whether the absence is due to an FMLA-qualifying event.
1/2004
EMPLOYEE CALL/REPORT-OFF FORM
PART 1
Questions and Statements Must Be Read As Written
Employee Name:
Time of Call:
Date of Absence:
Work Schedule:
Phone Number
(This Should be a number where the employee can be reached today for follow-up purposes as necessary)
REASONS FOR ABSENCE:
IF SICK LEAVE, IS REASON FOR:
Illness
Spouse
Bereavement
Self
Parent
Accident
Son/Daughter
Vacation
Other (Specify)
Other ________________________
Personal
(specify)
Comments:
If absence is for an illness for you or your family member, do you have a State Of Ohio Physician or Health Care
Yes
No
Provider Certification For The Family & Medical Leave (ADM 4260 ) for this condition?
Part 2
Part 2 is completed if the employee is using sick leave and does not have a certified ADM 4260 form for this condition.
The questions under Part 2 are asked and the form is completed by the employee's supervisor or designee.
How Long are you going to be absent?
Yes (In-patient)
No (Out-patient)
Will you or your family member be hospitalized?
Yes
No
Will you be applying for disability benefits?
Will you be applying for Workers' Compensation?
Yes
No
Will you or your family member see a medical professional for this absence?
Yes
No
Yes
No
Are you under continuing care or treatment for this condition?
If any of the questions were answered YES, please immediately forward this form to the
Office of Employee Services 30 E Broad St 40th Floor; Fax 728-4683
:
Call taken by
(Supervisor or Designee Department)
Date
Phone #
Supervisor's Signature
Date
Phone #
NOTE: The employee should not be asked to disclose confidential medical information (I.e., diagnosis or prognosis).
The Office of Employee Services may follow-up to determine whether the absence is due to an FMLA-qualifying event.
1/2004