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Staff Sick Time Form

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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:

  • Date Format: 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.

  • Date Format: MM slash DD slash YYYY