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Run: Sick Leave Notification Form

A Sick Leave Notification Form for employees to report an illness, share leave dates, and flag whether FMLA may apply. It also captures return-to-work planni...

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Employee Information

Employee name (required)

Employee ID

Department

Notify manager or HR (required)

Leave Details

Leave start date (required)

Leave end date

If you do not know the end date yet, leave this blank and provide the expected duration below.

Expected duration (days)

Estimate the number of workdays you expect to be absent.

Absence type (required)

Expected hours away

Reason and Medical Status

Reason category (required)

May this absence qualify for FMLA? (required)

Additional context

Provide only brief, work-relevant context. Do not include sensitive medical details unless requested by HR for a lawful purpose.

Return to Work Planning

Expected return date

Work coverage needed? (required)

Coverage notes

List only essential handoff details, deadlines, or contacts needed for coverage.

Return-to-work notes

Use this field for any return-to-work planning, restrictions, or accommodation requests. If an ADA reasonable accommodation may be needed, HR may follow up separately.

Attestation and Consent

I confirm the information provided is accurate to the best of my knowledge. (required)

Yes No N/A

I understand this form collects limited PII for HR and manager leave administration and may be retained in an audit trail. (required)

Yes No N/A

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