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Sick Pay Request Form
"I need a Sick Pay Request Form for my technology company with 50+ employees based in California, which must comply with both state and federal regulations while including specific fields for remote work arrangements."
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
Authors
Leave Duration
Reason for Leave
Medical Certification Requirements
Privacy and Confidentiality
Payment Terms
Return to Work
Certification and Declaration
Authorization
Documentation Requirements
Leave Balance Information
Company Policy Reference
Approval Process
False Statement Consequences
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