Victoria University – Employee Absence Self Declaration Form
In order to track COVID-19 related absences, all faculty, staff and librarians who are absent due to cold
or flu-like symptoms OR who must self-isolate based on public health advice must complete this form.
At this time, employees are not required to provide a doctor’s note or medical certificate for cold or flu-
related absences, or for self-isolation. For more information, please see Victoria University’s website for
updates. Individuals who are sick or self-isolating must also contact their Manager as per normal
practice to inform them of their absence.
Individuals who are symptomatic with cold and flu symptoms should select the Sick Leave option below.
These individuals should not attend work and should seek medical advice. Individuals who are not
symptomatic for COVID-19 but meet the criteria for self-isolation based on public health advice should
select the Self Isolation option below.
Where possible, self-isolating individuals should work from home during this 14-day period. If symptoms
of illness arise, please resubmit this form and follow the sick leave procedures outlined above.
Name: Personal Contact #:
Dept/College: Manager’s Name:
Emergency Contact Information
Contact Name: Relationship:
Phone Number: Email:
Absence Type: Please initial one of the boxes below:
Those Impacted by COVID School or Daycare Closures
Estimated End Date:
Consent to Release Medical Information (optional)
I hereby authorize my local public health authority to release my isolation status to Victoria University Human
Please forward completed Form to email@example.com attention Joanne Evans, Director,