The Sick Pay Request Form is a crucial document used across U.S. organizations to manage employee sick leave requests in compliance with federal and state regulations. This form should be used whenever an employee needs to take paid time off due to illness, medical appointments, or related health issues. It includes essential fields for employee identification, leave duration, and reason for absence, while respecting medical privacy requirements. The document ensures proper documentation for both employer compliance with sick leave laws and employee protection under various federal acts including FMLA, ADA, and state-specific paid sick leave regulations.
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1. Employee Information: Basic details including name, employee ID, department, contact information, and employment status
2. Leave Request Details: Specific information about the requested sick leave including start date, end date, and total number of days/hours
3. Reason for Leave: General category of illness or medical need, without requiring specific medical details
4. Available Leave Balance: Current sick leave balance and calculation of remaining leave after this request
5. Certification: Employee declaration and signature confirming the truthfulness of information provided
1. Medical Documentation Request: Optional section for cases requiring medical certification, typically for extended illness or as required by company policy
2. FMLA Qualification: Section to be included if the leave might qualify under FMLA, including rights and responsibilities
3. Return to Work Authorization: Section for cases where medical clearance is required before returning to work
4. Reasonable Accommodation Request: Section to be included if the employee requires workplace accommodations upon return
1. Schedule A - Medical Certificate Form: Template for healthcare provider to complete when medical certification is required
2. Schedule B - Company Sick Leave Policy: Reference copy of relevant company sick leave policies and procedures
3. Schedule C - State-Specific Leave Rights: Summary of applicable state sick leave laws and employee rights
4. Schedule D - Return to Work Requirements: Checklist and requirements for returning to work after extended sick leave
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