Sick Time Form

Use this form to request sick time. To ensure the integrity of our workplace and the fairness of our sick leave policy, we kindly request that all employees submit their sick time with accuracy and honesty.

Under the Massachusetts Earned Sick Time Law (M.G.L. c. 149, § 148C), employers are permitted to ask employees to verify that an instance of sick leave of any length was used for an authorized purpose under the law. Please complete the form below to file your sick leave request

First name

Last name

The sick time is to be utilized on the following start date:

I need to use earned sick time in the amount of hours.

Choose the Appropriate Use of Sick Time from the Options Below (Required)

Multi choice

To care for my child, spouse, parent, or parent of my spouse, who is suffering from a physical or mental illness, injury, or medical condition that requires home care, professional medical diagnosis or care, or preventative medical care;

to care for my own physical or mental illness, injury, or medical condition that requires home care, professional medical diagnosis or care, or preventative medical care;

to attend a routine medical appointment or a routine medical appointment for my child, spouse, parent, or parent of my spouse;

to address the psychological, physical, or legal effects of domestic violence; or

to travel to and from an appointment, a pharmacy, or other location related to the purpose for which the time was taken.

Agreements

I understand that if an employee is committing fraud or abuse by engaging in an activity that is not consistent with allowable purposes for earned sick time under M.G.L. c. 149, § 148C, an employer may discipline the employee for misuse of sick leave.

I understand that if an employee is exhibiting a clear pattern of taking leave on days just before or after a weekend, vacation, or holiday, an employer may discipline the employee for misuse of earned sick time, unless the employee provides verification of authorized use under M.G.L. c. 149, § 148C.

By signing below, I confirm that the above statements are truthful and accurate to the best of my knowledge

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

(833) 353-2828

Sick Time Form

Choose the Appropriate Use of Sick Time from the Options Below (Required)

Agreements

SCHEDULE YOUR SERVICE TODAY!

(833) 353-2828