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Employee
Verification Regarding Authorized Use of Earned Sick Time
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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.
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I,
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(type name), attest that I used
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earned sick time for the authorized reason/s
checked below:
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to care for my child, spouse, parent, or parent of
my spouse, who is suffering from
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a physical
or mental illness, injury, or medical condition that requires home care,
professional medical diagnosis or care, or preventative medical care;
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to care for my own physical or mental
illness, injury, or medical condition that
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requires home care,
professional medical diagnosis or care, or preventative medical care;
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to attend a routine
medical appointment or a routine medical appointment for my
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child, spouse, parent, or parent of my
spouse;
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to address the
psychological, physical, or legal effects of domestic violence; or
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to travel to and from
an appointment, a pharmacy, or other location related to the
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purpose for which the time was taken.
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I used earned sick time in the amount of
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hours and
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minutes on the
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following date/s:
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(date/s).
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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.
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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.
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By typing
my name in the Employee Signature line below, you are signing this
application electronically and attesting the information provided is
accurate. You agree that your electronic signature is the legal equivalent of
your manual signature on this application.
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Employee Signature (Print Name)
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Employee Email
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Date Signed
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