Employee CallOut Form – RVA

Expected Procedure for Callout:
1. Call the hospital (804.206.9122) and notify the Shift Advocate of absence at least two hours prior to scheduled shift.
2. Complete the form below.

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Team Member Name *

First

Last

Email *

Best Contact (Phone) Number

Date of Absence

Time of Callout

Name of Supervisor NotifiedSelect Your Supervisor Brenda Sue SomesChristy SchwartzJosh RoweLauren SprouseMary DieterichMichele Eggleston

Anticipated Return to Work Date

Reason for Absence

• Illness – Self
• Illness – Child
• Illness – Parent
• Illness – Other
• Bereavement
• Accident
• Personal
• Weather-Related
• Other

Specify Weather-Related Call Out *

Specify Other Call Out *

Weather-Related Best Absence

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