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Pandemic Absence Report : H1N1 Virus

Pepperdine University's pandemic response plan seeks to pro-actively safeguard against the potential health risks presented by an infectious disease outbreak. In order to best protect University community members, it is important for the University to collect information related to sick absences of staff and faculty.

[This information will be kept confidential and shared on a need-to-know basis only.]

I am reporting an absence for...
Myself
An employee that reports to me
A Coworker
Absentee Information
First Name*
Last Name*
Campus*
School / Dpt.*
Phone Where Employee May Be Reached *
Supervisor Name*
First Date Out of Office*
The absence is due to...   (*select all that apply)
A suspected case of a H1N1 virus
A confirmed case (by a physician) case of H1N1 virus
The employee's need to care for a family member with a suspected case of H1N1 virus
The employee's need to care for a family member with a confirmed (by a physician) case of H1N1 virus
Other miscellaneous illness
Has the employee traveled recently?
Has the employee been exposed to H1N1 virus?

Any Additional Information: