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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.

Mobile phone or best number to reach you
(If you do not have an email address, just put
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
(Please check all that apply. Work-related injuries must be called into HR immediately.)
Click or drag a file to this area to upload.
Please upload any documents related to test results, if required, or you can email to
Name of the child/adult with whom I was scheduled to work
MUST list dates and hours scheduled and reason care was cancelled (eg. Monday 1/2/2023 from 5pm-8pm=3 hours. I was too ill to work.) You can put multiple dates/times if that applies.
Name of the child/adult with whom I was scheduled to work
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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