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Sick and Safe Time Off Request
This form is for employees who work in Bloomington or Minneapolis, only. Please complete this form if you wish to utilize your accrued sick and safe paid time off. Time off can be requested in 4 hour increments.
Employee Name
Note below the hours you wish to take off, and receive Sick and Safe pay.
(Example: date, hours requested off)
By checking the box below, I am attesting that the time off I am requesting, qualifies under Sick and Safe law in the City of Bloomington or Minneapolis.
check here
Signature
Clear
