Personal Illness of Employee. (i) In the event an employee is unable to perform his/her work on account of personal illness, physical disability, or personal injury not covered by Worker‟s Compensation, the employee will be granted paid leave within his/her earned and accumulated paid leave time.
Personal Illness of Employee. B. Illness in the immediate family (spouse and dependent children) requiring doctor's care, or death in the immediate family, sister-in-law, brother-in-law, grandmother, grandfather of such employee, reasonably requiring leave of absence of such employee. Illness in the immediate family shall be limited to one (1) week unless illness requires an out of area stay, and then limit will be extended to thirty (30) days. Extensions available if approved by personnel director.
Personal Illness of Employee. TO BE COMPLETED BY MEDICAL PROVIDER (Additional information may be attached) Medical Provider (print name): __________________________________________ Licensed Profession (circle one): licensed physician physician’s assistant nurse practitioner chiropractor dentist Address: _______________________________________________________________ Phone Number: _________________________ _________________________________ was examined by me on _________________ (Patient Name) (Date) He/she was incapacitated by personal illness or injury due to______________________ _______________________________________________________________________ (Nature of illness unless it is of a confidential nature) or the appointment with the licensed medical or dental professional could not reasonably be scheduled outside of normal working hours for purposes of medical treatment or diagnosis of an existing medical or dental condition. He/she could not perform his/her duties on_____________________________________ (Date of incapacitation) and may return to work with no restrictions on____________________________. __________________________ ________________________ Signature of Medical Provider* Date (*If a signature stamp is used, it must be accompanied by the initials of someone authorized to do so.) MASSACHUSETTS DEPARTMENT OF CORRECTION
