Kin Care Use Request Form Santa Clara County Ambulance

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 receive corrective action up to termination for such a violation of company policy.

Full Name*

Employee Number*

Email*

Enter Email Confirm Email

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Email

Scheduled Unit*

Hours Requested off Start and End Time*

Date of Absence*

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Reason Taking Kin Care

Please select one reason you are taking time off from work for Kin Care:

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Family Member Requiring Care

Please select the eligible family member

Notes to the Supervisor

Upload Documentation Certifying Absence is Valid Kin Care Usage

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 2 MB, Max. files: 5.

Certification shall be sufficient in the form of any of the following:
(A) A police report indicating that the employee was a victim of domestic violence, sexual assault, or stalking.
(B) A court order protecting or separating the employee from the perpetrator of an act of domestic violence, sexual assault, or stalking, or other evidence from the court or prosecuting attorney that the employee has appeared in court.
(C) Documentation from a licensed medical professional, domestic violence counselor, as defined in Section 1037.1 of the Evidence Code, a sexual assault counselor, as defined in Section 1035.2 of the Evidence Code, licensed health care provider, or counselor that the employee was undergoing treatment for physical or mental injuries or abuse resulting in victimization from an act of domestic violence, sexual assault, or stalking.

Reference: CA Labor Code 230, CA Labor Code 233 CA Labor Code 234 CA Labor Code 245.5 CA Labor Code 246.5

Acknowledgement*

By clicking the box below I acknowledge that the information I am submitting is true and accurate.

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Kin Care Use Request Form