Please select who is filling out this form* Employee Other Name PhoneEmailPlease supply your email so that you can receive a copy of what you have submitted today for your records as well as the instructions on what to do next. We asked for a personal email as you are not at work to receive work email. The date in which the employee is calling out.* MM slash DD slash YYYY Demographic and contact informationEmployee Name*Please provide the employees full name that is calling out. Personal Phone Number*Please provide the best contact telephone number for the employee.Personal Email to contact Division* Admin Commissioner’s office DESC DMV FMO FSTEMS Hearings Highway Safety HSEM State Police Supervisor's name This information is to notify your supervisor that you will not be at work. No additional information other than your name and that you called out will be sent to your supervisor.Your supervisor's email address Please provide your supervisor’s email address.What was your reason for being out? Sick – Non-work related Injury Sick – Illness Sick – Appointment Approved FMLA Event Work Related Injury Other HiddenTested Positive for COVID19Please follow Public Health’s guidelines, which can be found here isolation-and-quarantine-recommendations (nh.gov). If you have any questions, please contact your supervisor or hrmedical@dos.nh.gov for assistance. We hope you feel better quickly!HiddenCOVID19 ExposurePlease follow Public Health’s guidelines, which can be found here isolation-and-quarantine-recommendations (nh.gov). If this is a household exposure, please see the flowchart created here household contact exposure flowchart (nh.gov). If you have any questions, please contact your supervisor or hrmedical@dos.nh.gov for assistance. We hope you feel better quickly!Sick – Non-work related injuryYou have been cleared to return from work once you are able to.Sick – Illness Do you have a pending COVID19 test? Yes No Thank you for taking time off when you aren’t feeling well. Please feel free to return when you feel better. If you have COVID like symptoms, please consider getting a COVID test. Sick – Appointment You are clear to return. Approved FMLA PlanDo you have an approved FMLA plan?* Yes No By choosing yes you are certifying that HR has approved you for a current FMLA plan and that today’s call out is consistent with that FMLA plan.Please contact hrmedical@dos.nh.gov for additional information..Work Related InjuryA message has been sent to Human Resources and someone will be contacting you.OtherWhat is the reason you are out?Additional InformationPlease provide any additional informationCAPTCHA