The Commonwealth of Massachusetts                            	         Telephone (617) 727-3777 
Human Resources Division, Civil Service Unit	                          Toll Free w/in MA: 1-800-392-6178
One Ashburton Place, Room 301, Boston, MA 02108		TDD: (617) 727-7583

HUMAN RESOURCES DIVISION
EMERGENCY EMPLOYMENT NOTIFICATION FORM FOR APPOINTMENTS IN CITIES AND TOWNS

To be filled out in quadruplicate and all Forms to be sent to the Human Resources Division, John W. McCormack State Office Building, 1 Ashburton Place, Boston, MA 02108.  If local officials require a copy, one extra copy should be forwarded to this office.

City or Town of: ______________________________

Department of: _______________________________ 

Division of: __________________________________ 

Date: _______________________________________

THESE FORMS ARE TO BE USED FOR EMERGENCY APPOINTMENTS ONLY.

	 

To the Personnel Administrator: 	
Under Civil Service Law, I hereby	 report the emergency employment*
	 request permission to renew the emergency employment**

of…………………………………………………………………………………………………………………………………………..…..
        	 Name		Date of Birth	                Social Security Number

Address………………………………………………………………………………………………………………………………….……
						 	per hour
Position………………………………………………at the rate of …………………….	…………per day…………………………...…
										  hours
From………………………………………………….for……………………………………………………………………….…… days
			(If actually employed for less time, notify the Human Resources Division)

Reason………………………………………………………………………………………………………………………………………
	                                     (Definite reasons must be stated in order to have emergency approved)

*Original emergency employment may not exceed a period of 30 days within 60 consecutive days following the date of appointment.  
**Emergency employment may be renewed for one additional period in the same twelve month period, only after the expiration of the original 60-day period.

In departments, institutions and hospitals the functions of which are connected with the public safety or public health, emergency employment may be renewed for a second period in the same twelve-month period. 

Emergency employment only in the position of LABORER may be renewed immediately after the original emergency employment for a period not to exceed 15 days, in which event emergency employment may not be further renewed in the same twelve-month period.

Intermittent or part-time employment should be reported on an hourly basis but in no case shall such employment exceed 240 hours in the 60-day period immediately following the date of the original appointment, renewal or renewals as the case may be.

N.B.  If more than one appointment has been made to the positions, the names of the appointees should be listed in alphabetical order – double space – on the reverse side of the form together with address, dates of birth and Social Security Number.  If all appointees are not to be employed for the same length of time, the date of appointment of each and the number of days should be listed.

……………………………………………………………………..

Title……………………………………………………………….
                              (Officer authorized to make appointments)

APPROVED
HUMAN RESOURCES DIVISION 
by:

I hereby certify that the employment reported above was to meet an emergency which could not have been foreseen and that the public business would be seriously impeded by delay in filling this position in the manner provided by the Civil Service Law and Rules.

	

Upon receipt of this report or request for renewal of employment properly filled out, if approved by the Personnel Administrator, copies will be forwarded to the proper officials in order that the employees may receive the compensation due him.