Forms, Letters & Notices
The following templates are provided for agency use. They may be customized to include agency-specific details, such as contact information for your HR office. However,
agencies should NOT make changes to the wording of the documents themselves. Any questions regarding customization of templates should be directed to OA-Human Resources'
Bureau of Employee Absences and Safety at 717.346.4667.
Please note that forms must often accompany specific letters.
Only a permanent employee with at least 1 year of credited service is eligible to use additional accrued sick absence quota
for the purpose of caring for the illness/injury of their qualifying family member. The employee must use 20 days (150/160 hours) of absence for the family member’s
illness/injury before requesting to use additional sick absence quota for this purpose. A period of 20 days must be met for each separate family member and/or health
condition within each leave calendar year.
- Request for Additional Sick Family Absence: Completed by the employee, signed by the approving authority and approved by the human resource office. The allowance may
only be granted after the employee has already exhausted their sick family entitlement for the current leave calendar year. The additional sick family absence must be used
prospectively and may not be retroactively applied to any of the initial qualifying hours.
Some unions have bargained for the inclusion of same-sex domestic partners and family members of domestic partners as family members for the purposes of sick family, sick bereavement, additional sick family, family care absence, and donated leave.
Domestic Partnership Verification: Must be completed to qualify for the commonwealth absence benefits. The employee and partner must meet the criteria noted on the form, along with 3 proofs that the same sex domestic partnership existed for at least 6 months.
- Domestic Partnership Termination: Must be provided within 30 days of terminating the domestic partnership.
The Leave Donation Program is designed for employees to donate accrued (actual) annual and personal absence quota to individuals who are
approved to receive leave donations for a catastrophic injury or illness. Management and non-represented employees and employees covered under a bargaining unit that has
entered into a side letter agreement with the commonwealth may qualify to receive leave donations if the injury or illness can be defined as severe.
Only a permanent employee with at least 1 year of credited service is eligible for a special extension of sick leave when all accrued and anticipated annual, personal, combined, and sick leave and all accrued holiday and compensatory leave has been used.