ESST Request

1
Employee Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Contact #* This field is required.Please provide the best way to contact you.
Please enter a valid phone number.
4
Date of Absence* This field is required.
Date
Month
Day
Year
5
Time Requested* This field is required.Minutes will be rounded to the nearest quarter hour.
00
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
Hour
00
00
05
10
15
20
25
30
35
40
45
50
55
Minutes
6
Does your request include Multiple Days?
One DayMultiple Days
7
Other Dates and TimePlease include the # of hours for each day requested in the below box.
8
ESST Reason* This field is required.
the employee’s mental or physical illness, treatment or preventive care;
a family member’s mental or physical illness, treatment or preventive care;
absence due to domestic abuse, sexual assault or stalking of the employee or a family member;
closure of the employee’s workplace due to weather or public emergency or closure of a family member’s school or care facility due to weather or public emergency; and
when determined by a health authority or health care professional that the employee or a family member is at risk of infecting others with a communicable disease.
9
Family Members Included* This field is required.
N/A - (Absence is for employee only)
their child, including foster child, adult child, legal ward, child for whom the employee is legal guardian or child to whom the employee stands or stood in loco parentis (in place of a parent);
their spouse or registered domestic partner;
their sibling, stepsibling or foster sibling;
their biological, adoptive or foster parent, stepparent or a person who stood in loco parentis (in place of a parent) when the employee was a minor child;
their grandchild, foster grandchild or step-grandchild;
their grandparent or step-grandparent;
a child of a sibling of the employee;
a sibling of the parents of the employee;
a child-in-law or sibling-in-law;
any of the family members listed in 1 through 9 above of an employee’s spouse or registered domestic partner;
any other individual related by blood or whose close association with the employee is the equivalent of a family relationship; and
up to one individual annually designated by the employee.
10
Impacted Client(s) for Absence* This field is required.Name of Client(s) whose shift will be impacted due to this absence.
11
Notes
Huge
Large
Normal
Small
Ok
Ok
12
Signature* This field is required.
Clear
Should be Empty: