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 checked 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/s).    
                       
  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 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.  
   
   
 
     
  Employee Signature (Print Name)   Employee Email  
                       
             
  Date Signed