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DOS Employee sick notification – DRAFT

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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?
- Tested Positive for COVID19
- COVID exposure
- Sick - Non-work related Injury
- Sick - Illness
- Sick - Appointment
- Approved FMLA Event
- Work Related Injury
- Other
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!
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

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We are committed to training, educating, and certifying emergency and community responders to protect the citizens and visitors of New Hampshire.

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Concord, New Hampshire 03301

fstems@dos.nh.gov

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Division of Fire Standards and Training & Emergency Medical Services. All Rights Reserved.

Search for:

About
- Who We Are
  Meet the Director
  
  Staff & Instructors
  
  History
  
  “First Alarm” Series
  
  Facilities
  Richard M. Flynn Training Facility, Concord
  
  Raymond S. Burton Training Facility, Bethlehem
  
  Northern EMS Field Office, Gorham
  
  Training Props
  
  Apparatus
  
  Training Grounds Coffeehouse
  
  Initiatives
  COVID-19
  
  Automated External Defibrillator (AED) Registry
  
  Organization
  Fire Standards & Training Commission
  
  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
News
- Kitchen Table Conversations
  
  News
Courses
- Courses
  Course Catalog
  
  Current Courses
  
  Examinations
  
  Online Classroom
  
  Registration
  
  Course Registration
  Register Today
Licensing
Resources
- Student Resources
  Support
  
  BLS Eligibility to Test Application
  
  Certification Reciprocity
  
  Online Classroom
  
  Skills University
  
  Public Resources
  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 (Version 8.1)
  
  Preplanned EMS Standby Coverage Best Practices
  
  Statewide Employment Opportunities
  
  Department Resources
  Academy Resource Request
  
  Department Information Update
  
  Department Training Request
  
  Instructor & Coordinator Resources
  Academy Resource Request
  
  Continuing Education Submission Form
  
  Curricula
  
  EMS Instructor/Coordinator Resource Manual
  
  EMS Request for Examination
  
  Initial Course Request Form (CREF)
  
  Instructor Application & Renewal
  
  Instructor Mentoring Program
  
  Instructor Policies
  
  Online Course Intake Request
  
  Paramedic Interfacility Transfer Instructor Materials
  
  Reciprocity Application Form
  
  Certification Reciprocity
Careers