Date:
Employee Name:
Employer Name:
Employee’s Phone Number:
Employee’s Email Address:
I am requesting Paid Sick Leave from _________________ (date/time) to ________________ (date/time) for one of the following reasons.
- to seek diagnosis, care, treatment or preventive care for myself or someone close to me including: a parent, sibling, child, spouse, registered domestic partner, grandparent, grandchild or a designated person (___________________)
- to seek medical treatment for injuries related to domestic violence, sexual assault or stalking; receive services from a shelter, program or crisis center; psychological counseling related to domestic violence, sexual assault or stalking; participating in safety planning; or relocating.
If you need more information, please contact me using the above information.
[Employee Signature]
Employees working in California are entitled to five (5) 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://legalaidatwork.org/factsheet/new-california-law-sb-616-increases-paid-sick-leave-from-3-to-5-days/
You do not need to disclose to your employer the reason why you are requesting Paid Sick Days. Paid Sick Days can be accrued and used regardless of immigration status.
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.
Disclaimer: Current as of January 2024. 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. 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.