Dlr Form 005 PDF Details

The Disability Leave Request Form, also known as Dlr form 005, is a document used by both employers and employees to request leave for a disability. This form allows employees to provide information about their disability and how it impacts their ability to work. It also gives employers the opportunity to ask questions about the employee's condition and request any supporting documentation. The Dlr form 005 must be completed in its entirety for the leave request to be considered.

QuestionAnswer
Form NameDlr Form 005
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namescharge 150e mgl 150e form

Form Preview Example

COMMONWEALTH OF MASSACHUSETTS

DO NOT WRITE IN THIS SPACE

DEPARTMENT OF LABOR RELATIONS

 

 

CHARGE OF PROHIBITED PRACTICE

Case No.

Date Filed

M.G.L. c.150E

 

 

INSTRUCTIONS: Answer all applicable questions. Failing to provide information may result in the dismissal of the charge.

Note: Pursuant to 456 CMR 15.04, the DLR will not issue a complaint unless the charging party has complied with the applicable provisions

of M.G.L. c.150E, §§13 and 14.

1.Employer

2. Representative to contact

4. Telephone Number

3.Address (street and No., city/town, state, and ZIP code)

5. Fax Number

6.Employee Organization (if any):

7. Representative to contact

9. Telephone Number

8.Address (street and No., city/town, state, and ZIP code)

10. Fax Number

11.This charge is filed against (check one)

Employer

 

Employee Organization

 

12.The above named employer or employee organization has engaged or is engaging in a prohibited practice within the meaning of Massachusetts General Law, Chapter 150E, Section(s) (enter all appropriate sections/subsections)

Failing to specify an appropriate section/subsection may result in the dismissal of the charge.

13.Summary of basis of Charge (be specific as to names, dates, addresses, etc.)

By these and other acts, the party complained of has interfered with, restrained, and/or coerced rights guaranteed by the Law.

DLR FORM-005 (page 1)

Revised 08/13

14.(a) Is there a collective bargaining agreement that may apply to the conduct that is alleged to have violated the Law?

Yes

No

(b)If you checked "Yes" in question 14(a), please list all of the clauses alleged to apply and attach a copy of each.

(c)Is there a grievance concerning this matter pending?

Yes No

15.Without limiting your rights to later amend your remedial request, please explain what remedy you seek. Include the amount of any financial remedy to which you claim entitlement.

16.Have you attempted to settle this case? If not, why not?

Yes

No

Note: The DLR may decline to issue a complaint unless reasonable settlement efforts have been made by the charging party. 456 CMR 15.04(1).

 

 

 

INFORMATION ON CHARGING PARTY

 

 

 

 

 

 

 

 

 

 

 

 

17.

Name

18. Representative to contact

20.

Telephone Number

 

 

 

 

 

 

 

 

 

 

19.

Address (street and No., city/town, state, and ZIP code)

21.

Fax Number

 

 

 

 

 

 

 

 

 

 

22.

The Charging Party is an:

 

Individual

 

Employee Organization

 

 

Employer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DECLARATION

I have read the above charge of prohibited practice and swear under the pains and penalties of perjury that the information contained in it is true and complete to the best of my knowledge and belief.

Name (print)

Signature

Title (if any)

Address (street and no., city/town, state, and ZIP code)

Telephone Number

CERTIFICATE OF SERVICE

I hereby certify that I have served a copy of this Charge of Prohibited Practice on the following representative of the opposing party.

Name

 

 

Address (street and no., city/town, state, and ZIP code)

Telephone Number

 

 

 

 

 

 

 

 

 

Method of Service

 

In hand

 

First Class Mail

 

Other (specify): ___________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Person making Certification

 

 

 

 

Telephone Number

 

 

 

 

 

 

 

 

 

The DLR does not discriminate on the basis of disability in access to its services. Inquiries, complaints or requests,

 

including requests for auxiliary aids and information regarding access features should be directed to the

DLR FORM-005 (page 2)

ADA Coordinator (617) 626-7132. This document is available in alternative formats.

Revised 08/13

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Completing this PDF requires care for details. Make sure that each blank field is filled out correctly.

1. Whenever submitting the Dlr Form 005, make certain to include all of the essential blanks in their corresponding form section. It will help to speed up the work, allowing for your information to be processed without delay and correctly.

Filling in segment 1 of Dlr Form 005

2. Soon after completing this section, go to the next stage and fill in the necessary particulars in these blanks - a Is there a collective bargaining, Yes, b If you checked Yes in question a, No Without limiting your rights, Yes, c Is there a grievance concerning, amount of any financial remedy to, Have you attempted to settle this, If not why not, Yes, Note The DLR may decline to issue, INFORMATION ON CHARGING PARTY, Name, Representative to contact, and Telephone Number.

Step number 2 in submitting Dlr Form 005

People frequently make some mistakes while completing Note The DLR may decline to issue in this section. Don't forget to read again what you type in here.

3. The following step is rather straightforward, Address street and No citytown, Fax Number, The Charging Party is an, Individual, Employee Organization, Employer, DECLARATION, I have read the above charge of, Title if any, Signature, Address street and no citytown, Telephone Number, CERTIFICATE OF SERVICE, I hereby certify that I have, and Address street and no citytown - every one of these empty fields will need to be filled out here.

Tips on how to complete Dlr Form 005 part 3

4. The subsequent section arrives with all of the following blank fields to complete: Signature of Person making, Telephone Number, and The DLR does not discriminate on.

Writing section 4 in Dlr Form 005

Step 3: Prior to moving forward, you should make sure that blank fields are filled out the correct way. When you believe it is all fine, click on “Done." Try a 7-day free trial option with us and acquire direct access to Dlr Form 005 - download or modify from your personal account page. FormsPal guarantees your data confidentiality with a secure method that never saves or shares any personal information typed in. Be assured knowing your documents are kept safe when you work with our services!

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