Employee Sick Time Acknowledgment

EMPLOYEE SICK TIME ACKNOWLEDGMENT

Employer Name:    Location/Worksite:

Personal Information

Position Information

Employment Status: Full-Time Part-Time Temporary

Employment History (Most Recent Two Employers)

Dates Employed: to

Dates Employed: to

Education

References (Professional)

Legal Disclosures

At-Will Employment Statement: Employment with the employer is at-will unless a written agreement signed by an authorized representative states otherwise. Either the employee or the employer may terminate employment at any time, with or without cause or advance notice, except where modified by applicable collective bargaining agreement or employment contract.

Equal Opportunity Statement: The employer provides equal employment opportunity to all employees and applicants without regard to protected characteristics and complies with applicable federal, state, and local anti-discrimination laws.

Sick Time Policy — Acknowledgment and Terms

Receipt of Policy: I acknowledge that I have received and reviewed the employer's Sick Time Policy (the "Policy") and understand that my use of sick leave is governed by the Policy, applicable law, and any controlling collective bargaining agreement.

Accrual and Use: Sick time is accrued at the rate specified in the Policy and becomes available in accordance with the Policy. Accrued sick time may be used for the employee's own illness or injury, medical appointments, or to care for an eligible family member as defined in the Policy. Accrual rates, caps, and eligibility periods are set forth in the Policy and may be amended in accordance with law.

Notification and Documentation: Employees must provide advance notice of foreseeable absences and notify their supervisor as soon as practicable for unexpected absences. The employer may require reasonable documentation or certification for absences, including medical certification, when permitted by law or the Policy. Failure to provide required documentation may result in denial of paid sick leave and/or disciplinary action.

Carryover, Payout and Separation: Accrual carryover, caps, and payout on separation are described in the Policy. Where law requires carryover or payout, the employer will comply with applicable legal obligations. Any payout upon termination will be subject to employer policy and applicable law.

Coordination with Other Leave: Sick time may run concurrently with other leave entitlements (such as family or medical leave or disability leave) where permitted by law and employer policy. Use of paid sick time does not negate other statutory rights, and eligibility for additional leave will be determined in accordance with the employer's leave policies and applicable law.

Confidentiality and Medical Information: Medical information and any documentation provided to support a sick leave request will be treated as confidential medical records and maintained separately from the employee's personnel file, except where otherwise required by law.

Prohibited Retaliation: The employer prohibits retaliation against employees for exercising rights under the Policy or applicable law. If an employee believes they have been retaliated against for requesting or using sick time, they should report the matter to Human Resources.

Consequences of Misuse: Falsification of leave records, fraudulent requests for sick time, or other misuse of sick leave may result in corrective action up to and including termination of employment. The employer reserves the right to verify absences and to request additional documentation when consistent with the Policy and applicable law.

Policy Updates: The employer may update or modify the Policy as required by changes in law or employer practice. Employees will be notified of material changes in accordance with employer procedures.

Effective Policy Date:

I acknowledge that I have received a copy of the Sick Time Policy: Yes I understand my responsibilities under the Policy

Applicant Certification & Authorizations

I certify that all information provided on this form is true, accurate, and complete to the best of my knowledge. I understand that false statements, omissions, or misrepresentations may result in disciplinary action, up to and including termination of employment.

Authorization to Verify: I authorize the employer to contact prior employers and references provided on this form to verify employment history, job performance, and other information relevant to my employment and leave eligibility. I also authorize any previous employer or reference to release such information to the employer.

Background and Records Checks: I understand that the employer may, to the extent permitted by law, conduct background checks, verify credentials, and seek information concerning my suitability for employment and administration of leave, and I consent to such checks where required by employer policy and law. I further understand that additional consents may be requested for specific checks.

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