Skip to content
(603) 223-4200
fstems@dos.nh.gov
Mon - Fri: 8:00 - 16:00
Skills University
Online Learning Academy
Support
About
Close About
Open About
Who we are
Meet the Director
History
“First Alarm” Series
Meet the Director
History
“First Alarm” Series
Facilities
Richard M. Flynn Training Facility, Concord
Raymond S. Burton Training Facility, Bethlehem
Training Props
Apparatus
Richard M. Flynn Training Facility, Concord
Raymond S. Burton Training Facility, Bethlehem
Training Props
Apparatus
Initiatives
Automated External Defibrillator (AED) Registry
Training Reimbursement: New Recruitment, Retention, and Development Initiative Announced
Education Training Agency
On My Time Firefighter I&II Training Program
Automated External Defibrillator (AED) Registry
Training Reimbursement: New Recruitment, Retention, and Development Initiative Announced
Education Training Agency
On My Time Firefighter I&II Training Program
Organization
Fire Standards & Training Commission
FSTC Curriculum Projects
Emergency Medical & Trauma Services Coordinating Board
Medical Control Board
Trauma Medical Review Committee
Board & Committee Documentation
Fire Standards & Training Commission
FSTC Curriculum Projects
Emergency Medical & Trauma Services Coordinating Board
Medical Control Board
Trauma Medical Review Committee
Board & Committee Documentation
Bureau of Certification and Support
Bureau of Emergency Medical Services
Bureau of Firefighter Training
Bureau of Certification and Support
Bureau of Emergency Medical Services
Bureau of Firefighter Training
News
Close News
Open News
News
Kitchen Table Conversations
News
Kitchen Table Conversations
News
Courses
Close Courses
Open Courses
Courses
Course Catalog
Course Schedule
Examinations
Online Learning Academy
Course Catalog
Course Schedule
Examinations
Online Learning Academy
Licensing
Resources
Close Resources
Open Resources
Student Resources
Psychomotor Eligibility to Test Application
Certification Reciprocity
Learning Accommodation Request
Online Classroom
Skills University
Support
“On My Time” Firefighter I and II Training Program
Psychomotor Eligibility to Test Application
Certification Reciprocity
Learning Accommodation Request
Online Classroom
Skills University
Support
“On My Time” Firefighter I and II Training Program
Public Resources
Automated External Defibrillator (AED) Registry
EMS Simulation Program
How to Become a First Responder
Statewide Employment Opportunities
Trauma System
Automated External Defibrillator (AED) Registry
EMS Simulation Program
How to Become a First Responder
Statewide Employment Opportunities
Trauma System
First Responder Resources
A Guide for New Fire Chiefs
EMS Accolades Report
Licensing for Emergency Medical Services
Patient Care Protocols
Preplanned EMS Standby Coverage Best Practices
Statewide Employment Opportunities
A Guide for New Fire Chiefs
EMS Accolades Report
Licensing for Emergency Medical Services
Patient Care Protocols
Preplanned EMS Standby Coverage Best Practices
Statewide Employment Opportunities
Department Resources
Academy Resource Request
Department Information Update
Department Training Request
FSTEMS Staff Resources
Academy Resource Request
Department Information Update
Department Training Request
FSTEMS Staff Resources
Instructor/Coordinator Resources
Academy Resource Request
Curricula
EMS Request for Examination
Initial Course Request Form (CREF)
State Fire Instructor Application & Renewal
Instructor Examination Request
Instructor Mentoring Program
Instructor Policies
Online Course Intake Request
EMS Instructor Portal
Student Job Performance Report
Academy Resource Request
Curricula
EMS Request for Examination
Initial Course Request Form (CREF)
State Fire Instructor Application & Renewal
Instructor Examination Request
Instructor Mentoring Program
Instructor Policies
Online Course Intake Request
EMS Instructor Portal
Student Job Performance Report
Careers
DOS Employee sick notification – DRAFT
Home
›
DOS Employee sick notification – DRAFT
Please select who is filling out this form
*
Employee
Other
Name
Phone
Email
Please 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 information
Employee 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
This field is hidden when viewing the form
Tested Positive for COVID19
Please 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!
This field is hidden when viewing the form
COVID19 Exposure
Please 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 injury
You 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 Plan
Do 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 Injury
A message has been sent to Human Resources and someone will be contacting you.
Other
What is the reason you are out?
Additional Information
Please provide any additional information
CAPTCHA