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Sick Pay Form

If you are calling out sick for a scheduled shift for any reason, please complete the information below in full and one of our HR Associates may contact you if we have any questions. Some fields and responses are optional.

Name *

First

Last

Phone *

Mobile phone or best number to reach you

Email *

(If you do not have an email address, just put none@none.com)

Employee Number *

If you are a current employee, please put your employee number. If you do not know it, put UNK

Primary reasons for use of accrued Sick Pay *

• A communicable disease (eg. the flu, a cold, Covid-19) - Do not work until free of symptoms
• Medical appointment for myself
• I am too ill to work
• Other (must include comments in each family field below)

(Please check all that apply. Work-related injuries must be called into HR immediately.)

Family #1 *

Name of the child/adult with whom I was scheduled to work

Missed Schedule and Comments #1 *

MUST list dates and hours scheduled and reason care was cancelled (eg. Monday 1/2/2026 from 5pm-8pm=3 hours. I was too ill to work.) You can put multiple dates/times if that applies.

Family #2

Name of the child/adult with whom I was scheduled to work

Missed Schedule and Comments #2

See Comments #1 section above for directions. Please login to Paylocity, our payroll system, to view your current sick pay balance.

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