Employee Sick Time Request Form

The employee MUST complete, sign and submit this ‘Sick Time Off Request’ form in order to be paid for sick leave.

Additionally, YOU MUST CALL YOUR DIRECT SUPERVISOR & YOUR FOOTBRIDGE RECRUITER to provide notice of your time off.

Direct Supervisor Name: *

Phone *

FootBridge Recruiter Name: *

Phone *

First Name: *

I 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 effect 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.

Please provide the dates of your time off.

Date *

Number of Hours Taken

Date

Number of Hours Taken

Date

Number of Hours Taken

Date

Number of Hours Taken