Rev 12/2015
Hampshire College
Verification Regarding Authorized Use of Earned Sick Time or Sick Leave
I, (print or type name), attest that I used
earned sick time for the authorized reason/s checked below:
[
] to care for my child, spouse, domestic partner, parent, or parent of my spouse or domestic partner, who is
suffering from a physical or mental illness, injury, or medical condition that requires home care, professional
medical diagnosis or care,
or preventive 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 preventive medical care;
[
] to attend a routine medical appointment or a routine medical appointment for my child, spouse,
domestic partner, parent, or parent of my spouse or domestic partner;
[
] to address the psychological, physical, or legal effects 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.
I used earned sick time in the amount of ______hours and _____minutes (15 minute intervals)
on the following date/s: ___________________________________________________________ .
I understand that if I am committing fraud or abuse by engaging in an activity that is not consistent with
allowable earned sick/sick leave time purposes, I may face discipline for misuse of earned sick/sick leave time.
I understand that if I exhibit a clear pattern of taking leave on days just before or after a weekend, vacation, or
holiday, I may face discipline for misuse of earned sick time, unless I provide verification of authorized use.
Employee Signature Employee Name (Print)
Date Signed
click to sign
signature
click to edit
![]()
