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Employee Absence Report

Date:

Employee:

Report received by:

Expected number of days absent:

Expected date ofreturn:

Time of report:

Absence reported to:

Reported by: [ ] Self [ ] Other relative [ ] Friend

[ ] Spouse [ ] Supervisor [ ] Other

Expected date of return:

Reason

[ ] Illness

[ ] Illness in family

[ ] Injury on job

[ ] Transportation

[ ] Military duty

[ ] Death in family

[ ] Outside injury

[ ] Other

Comments:

________________________

Name and Position

(Company Personnel)

Signature