Staff Sick Time Form

Name: Zoar Outdoor
Address: 7 Main St., Charlemont, Massachusetts, 01339
Telephone: 413-339-4010

Sick Time

Employee Verification Regarding Authorized Use of Earned Sick Time

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.
I,
(type name), attest that I used earned sick time for the authorized reason/s below:
- 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.
I used earned sick time in the amount of
hours and
minutes
on the following date/s:
MM/DD/YYYY

MM slash DD slash YYYY
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.
Employee Name*
Confirm Employee Name*
Date*

MM slash DD slash YYYY

Staff Sick Time Form

Sick Time

Employee Verification Regarding Authorized Use of Earned Sick Time