Employee Name: _______________________________________________________________________
Employer Name: ________________________________________________________________________
Employee’s Phone Number: ___________________________________________________________________
Employee’s Email Address: ______________________________________________
I am requesting paid sick leave from _________________ (date) to ________________ (date) for the following reason:
- I am suffering from illness, injury, serious medical condition, and/or seeking preventive care, diagnosis, or treatment for an existing health condition.
- I am taking care of a family member – parent, parent-in-law, spouse (or registered domestic partner), child, sibling, grandparent, or grandchild – who is suffering from illness, injury, serious medical condition, and/or seeking preventive care, diagnosis, or treatment for an existing health condition.
If you need more information, please contact me at ___________________________________
Employees working in California are entitled to three (3) accrued California Paid Sick Days* and may be entitled to additional paid leave under local laws. For more information about California Paid Sick Leave, please visit: https://www.dir.ca.gov/dlse/paid_sick_leave.htm.
Employees experiencing an extended need for leave may also be protected under the California Family Rights Act or the Fair Employment and Housing Act, and eligible employees may be entitled to wage replacement under State Disability Insurance or Paid Family Leave. Please visit:https://calcivilrights.ca.gov/employment/pdl-bonding-guide/ to learn more.
* For Paid Sick Leave requests related to COVID-19, please visit: https://www.dol.gov/agencies/whd/pandemic/ffcra-employee-paid-leave.
Please be advised that due to the U.S. being in a state of emergency, laws and associated enforcement procedures are rapidly changing. Legal Aid at Work cannot ensure that this document is current nor be responsible for any use to which it is put. The contents of this document do not have the force and effect of law and are not meant to bind the public in any way. This document is intended to help workers who need to request leave due to being subject to a quarantine order or medically advised to quarantine. Do not rely on this information without consulting an attorney or the appropriate agency about your rights in your particular situation. This form is not legal or tax advice.