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Kin Care Use Request Form

  • By submitting this form I confirm that I was absent on the above date for a reason that qualifies as kin care.

    Reasons an employee can take time off from work for Kin Care:
    • Seek diagnosis, care or treatment for an existing health condition of an employee’s family member.
    • Support a family member that is the victim of domestic violence.
    • Support a family member that is the victim of sexual assault.
    • Support a family member who was the victim of a stalking.
    • Support a family member in completing any preventative healthcare service.
    Family Members are defined as:
    • Child – biological, adopted, foster, stepchild, legal ward, or a child for which the employee stands in loco parentis
    • Parent – biological parent, adoptive parent, foster parent, stepparent, or legal guardian of an employee or an employee’s spouse/domestic partner
    • Spouse
    • Registered domestic partner
    • Grandparent
    • Grandchild
    • Sibling
    By signing below, I am requesting that the above absence be charged against my sick leave/PTO bank and be counted as kin care, and I am certifying that the time off stated above meets the definition of kin care. I understand that providing false information about the use of sick leave, including the use of sick leave for kin care, is a violation of company policy and that I may be disciplined or terminated for such a violation of company policy.
  • Date Format: MM slash DD slash YYYY
  • Drop files here or
    Accepted file types: jpg, png, pdf.
  • By clicking the box below I acknowledge that the information I am submitting is true and accurate.