Forms → Staff → Benefits → Request for Leave under the Maryland Healthy Working Families Act
Form number: 430-1B
Audience: MCPS Staff
Last revised: July 2018
INSTRUCTIONS: To be completed by an employee who is not covered by an MCPS association agreement (e.g., temporary part-time employees) but is eligible for leave under the Maryland Healthy Working Families Act. Attach copies of appropriate documentation and submit them to your principal/supervisor or director, who will
send them to the director of ERSC for approval. Once approved, the form must be attached to the employee’s timesheet. See reverse side of the form for detailed information.
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