Form NPD-82 "Sick Leave Documentation - Gina Warning" - Nevada

What Is Form NPD-82?

This is a legal form that was released by the Nevada Department of Administration - a government authority operating within Nevada. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2011;
  • The latest edition provided by the Nevada Department of Administration;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form NPD-82 by clicking the link below or browse more documents and templates provided by the Nevada Department of Administration.

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Download Form NPD-82 "Sick Leave Documentation - Gina Warning" - Nevada

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Sick Leave Documentation – GINA Warning
WARNING LANGUAGE
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by
GINA Title II from requesting or requiring genetic information of an individual or family member of the individual,
except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic
information when responding to this request for medical information. ‘Genetic information’ as defined by GINA,
includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the
fact that an individual or an individual’s family member sought or received genetic services, and genetic
information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an
individual or family member receiving assistive reproductive services.
Date/time of documentation request:
Dates of sick leave:
Employee’s Certification
I certify that I have been provided the above GINA warning relating to my providing documentation of authorized
use of sick leave.
Employee’s name (print):
Employee’s signature:
Date:
Supervisor’s Certification (If a supervisor is unable to provide an employee with the above GINA warning in
writing at the time of requesting substantiating evidence of authorized use of sick leave, the supervisor may read
the above warning language to the employee and certify to that warning below.)
I certify that I read the above GINA warning language to the above named employee relating to a request for
substantiating evidence of authorized use of sick leave.
Date of reading:
Supervisor’s name (print):
Supervisor’s signature:
Date:
NPD-82
(7/11)
Sick Leave Documentation – GINA Warning
WARNING LANGUAGE
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by
GINA Title II from requesting or requiring genetic information of an individual or family member of the individual,
except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic
information when responding to this request for medical information. ‘Genetic information’ as defined by GINA,
includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the
fact that an individual or an individual’s family member sought or received genetic services, and genetic
information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an
individual or family member receiving assistive reproductive services.
Date/time of documentation request:
Dates of sick leave:
Employee’s Certification
I certify that I have been provided the above GINA warning relating to my providing documentation of authorized
use of sick leave.
Employee’s name (print):
Employee’s signature:
Date:
Supervisor’s Certification (If a supervisor is unable to provide an employee with the above GINA warning in
writing at the time of requesting substantiating evidence of authorized use of sick leave, the supervisor may read
the above warning language to the employee and certify to that warning below.)
I certify that I read the above GINA warning language to the above named employee relating to a request for
substantiating evidence of authorized use of sick leave.
Date of reading:
Supervisor’s name (print):
Supervisor’s signature:
Date:
NPD-82
(7/11)
This page is to be provided to the employee if the warning is provided in writing.
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities
covered by GINA Title II from requesting or requiring genetic information of an individual or family
member of the individual, except as specifically allowed by this law. To comply with this law, we are
asking that you not provide any genetic information when responding to this request for medical
information. ‘Genetic information’ as defined by GINA, includes an individual’s family medical history,
the results of an individual’s or family member’s genetic tests, the fact that an individual or an
individual’s family member sought or received genetic services, and genetic information of a fetus
carried by an individual or an individual’s family member or an embryo lawfully held by an individual or
family member receiving assistive reproductive services.
NPD-82
(7/11)
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