"Employee Certification of Necessary Absence Form" - Rhode Island

Employee Certification of Necessary Absence Form is a legal document that was released by the Rhode Island Department of Administration - a government authority operating within Rhode Island.

Form Details:

  • Released on September 9, 2014;
  • The latest edition currently provided by the Rhode Island Department of Administration;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Rhode Island Department of Administration.

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Download "Employee Certification of Necessary Absence Form" - Rhode Island

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Rev. 9/9/14
STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS
EMPLOYEE CERTIFICATION OF NECESSARY ABSENCE FORM
For Absences of Three (3) to less than Five (5) Consecutive Days
Due to Illness, Injury, or Exposure to Contagious Disease
Nothing contained herein exempts an employee’s obligation to comply with the employing agency's procedures for the notice and authorization of
such leave.
__________________________________________
__________________________________________
Employee’s Name (Last, First, MI)
Job Classification Title
(Please Print)
__________________________________________
__________________________________________
Department
Division/Unit
If leave is for the care of an immediate family member, indicate relationship: ________________________
(Immediate Family is defined as: Wife, Husband, Child (including Foster Child), Mother, Father, Brother, Sister, Mother-in-Law,
Father-in-Law, Grandmother, Grandfather, any other family relative residing in the employee’s household or domestic partner of the
same or opposite sex who have lived in the same household for at least six (6) months and have made a commitment to live as a
family)
Duration of Absence: from __________________________ through _________________________________
(Beginning Date of Absence)
(Ending Date of Absence)
Describe the relevant medical facts, either for your own condition, or your immediate family member
(i.e., nature of the problem):
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
I certify that the leave/absence requested above is/was necessary for the purpose(s) indicated and that there are
no willful misrepresentations or falsifications of the information provided. I understand that should an
investigation disclose such misrepresentations or falsifications, my authorization for such absence due to illness
shall be revoked and I shall be subject to appropriate disciplinary action, up to and including termination.
__________________________________________
______________________________
Signature
Date
RETURN THIS COMPLETED FORM TO YOUR HUMAN RESOURCES OFFICE
Notice
To protect employee privacy rights, all documents containing confidential medical information are maintained as confidential medical
records and are kept in separate, secure medical files in the Human Resources Service Center office. Access to these records is
restricted as provided by law. Nothing contained herein shall adversely affect an employee’s entitlement to leave pursuant to either
State or Federal Laws concerning Family/Medical Leave. All absences due to qualifying medical reasons shall count towards an
eligible employee’s leave under such laws. Qualified employees who require leave pursuant to the Family and Medical Leave Act
(FMLA) must complete and submit the required FMLA forms. For more information, contact your Human Resources Service Center.
All leave requests may be subject to investigation and audit.
Rev. 9/9/14
STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS
EMPLOYEE CERTIFICATION OF NECESSARY ABSENCE FORM
For Absences of Three (3) to less than Five (5) Consecutive Days
Due to Illness, Injury, or Exposure to Contagious Disease
Nothing contained herein exempts an employee’s obligation to comply with the employing agency's procedures for the notice and authorization of
such leave.
__________________________________________
__________________________________________
Employee’s Name (Last, First, MI)
Job Classification Title
(Please Print)
__________________________________________
__________________________________________
Department
Division/Unit
If leave is for the care of an immediate family member, indicate relationship: ________________________
(Immediate Family is defined as: Wife, Husband, Child (including Foster Child), Mother, Father, Brother, Sister, Mother-in-Law,
Father-in-Law, Grandmother, Grandfather, any other family relative residing in the employee’s household or domestic partner of the
same or opposite sex who have lived in the same household for at least six (6) months and have made a commitment to live as a
family)
Duration of Absence: from __________________________ through _________________________________
(Beginning Date of Absence)
(Ending Date of Absence)
Describe the relevant medical facts, either for your own condition, or your immediate family member
(i.e., nature of the problem):
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
I certify that the leave/absence requested above is/was necessary for the purpose(s) indicated and that there are
no willful misrepresentations or falsifications of the information provided. I understand that should an
investigation disclose such misrepresentations or falsifications, my authorization for such absence due to illness
shall be revoked and I shall be subject to appropriate disciplinary action, up to and including termination.
__________________________________________
______________________________
Signature
Date
RETURN THIS COMPLETED FORM TO YOUR HUMAN RESOURCES OFFICE
Notice
To protect employee privacy rights, all documents containing confidential medical information are maintained as confidential medical
records and are kept in separate, secure medical files in the Human Resources Service Center office. Access to these records is
restricted as provided by law. Nothing contained herein shall adversely affect an employee’s entitlement to leave pursuant to either
State or Federal Laws concerning Family/Medical Leave. All absences due to qualifying medical reasons shall count towards an
eligible employee’s leave under such laws. Qualified employees who require leave pursuant to the Family and Medical Leave Act
(FMLA) must complete and submit the required FMLA forms. For more information, contact your Human Resources Service Center.
All leave requests may be subject to investigation and audit.