Employee Call Off Sheet Form PDF Details

In the realm of managing employee absences, the Employee Call Off Sheet plays a pivotal role, especially within the framework set by the Ohio Department of Medicaid. This document serves as a crucial touchstone for documenting and processing time off requests, encompassing a wide array of leave types including vacation, personal, bereavement, and notably, sick leave. Each call-off incident is meticulously recorded in two major parts, with a third section activated under specific circumstances related to extended sick leave. From capturing the basic details of the employee’s name, office, and dates of absence to the finer points concerning the nature of the leave and whether it falls under the Family Medical Leave Act (FMLA), the form is comprehensive. It ensures that employees declare their reason for absence without breaching confidentiality around medical information, while also setting out clear directives on how unapproved leave without pay is handled. The involvement of Human Resources or Labor Relations to ascertain FMLA eligibility underscores the importance of adhering to federal laws regarding employee rights. The document anticipates various scenarios, including absences due to a family member's illness and the possibility of applying for disability benefits, making it an indispensable tool for both employees and their supervisors in navigating the often complex landscape of leave management.

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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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

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