EmailMe Form - Notification of Intention to use Paid Sick Leave

Today's Date *

MM / DD / YYYY

Your Name *

Your Email *

Click here and review your rights under Paid Sick Leave *

I hereby notify my intention to use earned paid sick leave hours as permitted under the NYC Paid Sick Leave Law

I understand that I have earned 1 sick hour for every 30 hours of work during a calendar year, up to 56 hours a year

I understand that I am entitled to unused earned sick hours carried over from the previous calendar year, up to a maximum of 56 hours a year

I understand that sick leave can be requested for (1) need for preventive medical care (2) need for medical diagnosis, care or treatment of a physical illness, injury, or health condition for myself or a family member.

ADVANCE NOTICE: If your need for sick leave is foreseeable, you must give us a 7-day advanced notice, in writing, of your intention to use paid sick leave.

Misuses of Paid Sick Leave *

I am aware that an employer may take disciplinary action, up to and including termination, against an employee who uses sick leave for purposes other than those provided for under the law.

The reason I am asking for paid sick is *

Doctor's note *

I understand that if I am requesting more than 3 consecutive days of paid sick leave, I will only be paid after I provide a doctors note within reasonable time. Payment will only be made only after I send that in

Date(s) or hour(s) that I will not be able to work and for which I am requesting paid sick leave *

I will be available to show up at work on the following date (add the first date you will be able to actually be at work) *

Feel free to make other notes here

Upload any doctor's notes etc

Signature *

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Sign your name with mouse or with your finger

Any questions? Call us at 212-614-8057 or email us at *

Questions re how many days I have for this year? Email Rosa at *

Questions re staffing? Email *