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-HR Service Center, Absence Services at 717.346.4667.
 
Please note that forms must often accompany specific letters.

• Additional Sick Family
• FMLA-Related Absences
• Leave Donation
• Required Postings
• Special Extension of Sick Leave
• Miscellaneous Absence Forms

Additional Sick Family

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.
  

Leave Donation

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. 

• Employee Serious Health Condition Certification: Completed by the health care provider.
• Medical Condition Certification to Receive Leave Donation: Completed by the health care provider.
• Request to Receive Leave Donations: Completed by an employee who wishes to receive a leave donation.
• Request to Donate Leave: Completed by an employee who would like to donate annual or personal leave. 
• Request to Receive Leave Donations Across Agencies: Completed by an employee who did not receive sufficient leave donations from employees within their own agency. This request form is used to request donations from employees who are located in another agency within a reasonable geographic area or from the recipient’s relative. 

Military Leave of Absence

Additional information is located in the Employee Resource Center, MD530.26 Military Leaves of Absence, and in the Uniformed Services Employment and Reemployment Rights Act.

• Request for Military Leave of Absence: Completed for periods of military service to request the absence and certain benefit entitlements.  
  
• Notice to Employees – Military Leave of Absence: Used to provide information about military leaves of absence to employees.
  
• Application for Reemployment from Military Leave of Absence: Completed for reemployment from military leaves of absence of more than 30 days.
• Military Leave of Absence Approval Letter: Used to notify employees of the approval of military leaves of absence.
• Military Leave of Absence Provisional Approval Letter: Used to notify employees of the provisional approval of military leaves of absence pending the receipt of additional information.
• Military Leave of Absence 5 Year Expiration Letter: Used to notify employees that the five year entitlement to military leave will soon expire. ​
  

Miscellaneous Absence Forms

• Medical Condition Certification for Sick Leave Absences for Regimented Treatment (PSCOA H1 use only):  Completed by the health care provider to determine an H1 employee’s eligibility for additional paid absence benefits that may be used intermittently for absence periods of less than six consecutive work days.