Employee Call Off Sheet Form PDF Details

In order to keep track of employees who are absent from work, many businesses use an Employee Call Off sheet. This document allows managers and supervisors to keep track of who is out, why they are out, and when they are expected to return. An Employee Call Off sheet can also be used to note any notice given to the employee about their absence in advance. Typically, the form includes fields for the employee's name, the date, the reason for absence, and whether notice was given. This blog post will provide an overview of what an Employee Call Off sheet is and discuss some of the benefits that can be derived from using one. It will also provide a link to a free downloadable template that businesses can use as a starting point for creating their own sheet.

QuestionAnswer
Form NameEmployee Call Off Sheet Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesemployee call in form, call out form, employee call in sheet, call off log

Form Preview Example

Ohio Department of Medicaid

EMPLOYEE CALL-OFF SHEET

PART 1

Part 1 is completed every time the employee calls off. (All questions must be completed and statements read as written.)

Employee Name

Employee Office/Bureau

Date and Time of Call

Work Schedule

Dates of Absence Including First day Out

Phone Number (A number where employee can be reached for follow-up purposes as necessary)

Leave Requested:

 

Vacation*

 

Personal*

 

Bereavement

Leave in Lieu of Sick Leave (Vacation, Personal, Comp Time)

*Employee must specify the nature of request if advance notice was not given:

Sick Leave Other*

Was verification of absence requested?

YES

Do you have sufficient accrued leave to cover this absence?

NO Explain:

YES

NO If “No”, read the following statement:

STATEMENT: Leave without pay must be approved by your appropriate chain of command on a case-by-case basis. Unpaid leaves in excess of one full pay period require advanced approval of the Director or Designee. Any unapproved/disapproved leave without pay will result in disciplinary action for AWOL up to and including removal.

If Sick Leave, is absence for:

Self

Spouse

Son/Daughter

 

Parent

 

Other (specify)

If this absence is for an FMLA condition, what is your FMLA #

. (If no FMLA #, see Part 3.)

PART 2

Part 2 is completed every time the employee calls off.

Call taken by (Supervisor or Designee)

Office or Bureau Telephone

Date

Supervisor Acknowledgment

Date

Note: The employee should not be asked to disclose confidential medical information (i.e., diagnosis or prognosis). Human Resources/Labor Relations may follow-up to determine whether that condition would constitute FMLA eligibility.

PART 3

Part 3 is completed every time the employee has used or will use more than three days of sick leave and does not have a certified ADM 4260 form for this condition. All questions under Part 3 are asked and the form is completed by the employee’s supervisor or designee.

 

How long are you going to be absent?

 

Have you or your family member ever seen or plan on seeing a medical professional for this

 

 

 

 

 

 

condition?

 

 

 

YES

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Will you be applying for disability benefits?

 

Will you or your family member be hospitalized?

 

 

 

 

YES

 

NO

 

 

YES

 

Inpatient

 

 

Outpatient

 

NO

 

 

 

 

 

 

 

 

 

Are you (or family member) under continuing care or treatment for this condition?

YES

NO

If absence is due to the illness of a family member, what care are you providing?

Were any of the questions in Part 3 answered “YES”?

 

YES

If “YES”, read the following statement (exactly as written) and

immediately Fax; scan and email; or hand deliver this form to the FMLA coordinator in Wellness Management (FAX Number 614-995-1302).

STATEMENT: Based upon the information that has been provided regarding this request for Sick Leave, I am notifying you that the Sick Leave you are currently on may be considered a qualifying event under the terms of the Family Medical Leave Act of 1993 and therefore charged against your twelve-week annual entitlement, provided sufficient documentation to establish your eligibility is submitted. The FMLA Coordinator will be sending you a letter explaining what information is necessary. Please be advised that this information must be supplied by a physician or health care provider.

NO. If “NO”, file this form for future reference.

ODM 00202 (7/2014)

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1. The employee call off log template will require specific information to be typed in. Ensure that the following fields are filled out:

Completing section 1 of employee call in log

2. When the last section is complete, you're ready to insert the needed specifics in Part is completed every time the, Office or Bureau Telephone, Date Date, Note The employee should not be, Part is completed every time the, Have you or your family member, YES, Inpatient, YES, YES, PART, Are you or family member under, YES, If absence is due to the illness, and Were any of the questions in Part in order to progress further.

Were any of the questions in Part, YES, and If absence is due to the illness inside employee call in log

3. This stage will be straightforward - fill in all the empty fields in STATEMENT Based upon the, NO If NO file this form for future, and ODM to conclude this part.

Tips on how to prepare employee call in log part 3

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