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Office of the Managing Director, City of Philadelphia

paidsickleave@phila.gov

1401 John F Kennedy Blvd, Suite 1430 Philadelphia, PA 19102

Document Signers

    • 1 Complainant

City of Philadelphia Promoting Healthy Families and Workplaces Complaint and Intake Form

Thank you for contacting the City of Philadelphia Managing Director's Office (MDO). Please complete the questions below. If a question does not apply to you, please mark is at Not Applicable.This version of the form is for complainant's over the age of 18 only. Click here if the complainant is under 18.

If you have any questions about this form or would prefer to have a staff member help you complete the form, please contact MDO at PaidSickLeave@phila.gov. If you prefer to use a language other than English, we can provide free translation assistance. In addition to filling out and submitting this form online, you can submit the completed form in the following ways:

  • Download and email to: PaidSickLeave@phila.gov
  • Download and mail to: Managing Director's Office, Attn: Paid Sick Leave Division, 1401 John F Kennedy Blvd, Suite 1430, Philadelphia, PA 19102

After MDO receives your completed form, we will contact you within fifteen business days to gather any additional information we need or to notify you what action we will be taking.

Employment Information

Please answer the following questions to help us determine if you are covered by Philadelphia's Promoting Healthy Families and Workplaces Law. Please see section 914c of the law for more details on qualifications.

Please indicate which of the following ways the employer has violated the law and provide further information in the space below. Check all that apply

Please provide any relevant documents along with this form (i.e., pay stub, employment contract, collective bargaining agreement, employer's policy on sick leave, and a copy of your request for sick leave). MDO does not need health related information to process your complaint. If you do provide any health information, MDO will treat it as confidential and will not disclose it without your permission or unless required by law.