Maryland Department of HealthDevelopmental Disabilities Administration (DDA)

Maryland Department of Health

Developmental Disabilities Administration (DDA)

Family as Staff Overtime Request Form

This form allows participants who self-direct their services to request family members to temporarily work overtime.

Participants who self-direct their services are solely responsible for ensuring that overtime work does not over-utilize funds in their Self-Directed Services budget.

Overtime pay may significantly affect budget utilization.

Any participant who requests overtime for family members more than once in a Person-Centered Planning year, will be subject to review to confirm that the Self-Directed Services model is appropriate for them.

Only the participant's Coordinator of Community Services may complete this form.

Please reach out to the DDA Regional Office if you have questions, concerns, or need technical assistance.

This form was updated on May 16, 2025.

Participant LTSSID*

Participant's Financial Management and Counseling Services Provider*

The Arc of Central Chesapeake Region

GT Independence

Public Partnerships LLC

Participant Name*

DDA Regional Office*

Central Maryland Regional Office

Eastern Shore Regional Office

Southern Maryland Regional Office

Western Maryland Regional Office

Family Member that is Requesting Overtime*

Overtime is defined as over 40 hours in a workweek.

Is the family member the participant's legal guardian or legally responsible person?*

Yes

Length of Request*

Choose how long the request is for

Brief (14 days or fewer)

Temporary (15 - 90 days)

Start Date of Requested Overtime*

List the first day the family as staff would work overtime.

Reason for the Brief Request*

Serious inclement weather

Sickness of participant

Sickness of an employee

Reason for the Temporary Request*

"Sudden notification" is defined as less than 15 days notice

Sudden notification of an employee's resignation

Sudden notification of an employee's death

Sudden notification of an employee intention to use unpaid leave

Immediate termination of an employee due to fraud, waste, or abuse

Participant has been unable to hire employees

Explanation of the Request for Overtime*

Explain in detail why the participant is requesting this family member employee to work overtime.

Schedule of Overtime Hours Requested*

Share the hours per week the family employee will be working by service. All waiver services the family employee works must be included.

Use the format:

[Day of the Week]: [Total Number of Hours]-[Start Time], [End Time], [Waiver Service]

Monday: 12 hours, 8am-8pm, Personal Supports

A schedule of the request and the Person-Centered Plan schedule must be uploaded with this request.

Number of Hours Requested per Week*

This is the total number of hours the family member is requesting to work per week.

Risk to Health and Safety*

In detail, explain how the participant has a risk to their health and/or safety without the overtime approved.

Are the hours requested already listed in the Person-Centered Plan?*

The DDA cannot approve overtime requests that allow more hours to be worked than what are listed in the Person-Centered Plan.

Yes

File Upload*

Requests must include documentation of the requested schedule of hours and Person-Centered Plan schedule.

Supporting documentation is also required to show the reason for the request such as:

Doctor's note showing employee or employer sickness
Dated resignation letter or termination letter
Participant attestation of death of an employee
Dated letter from employee requesting use of unpaid leave
Proof of advertisements and interviews

All requests without supporting documentation will be returned to the participant and their team.

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CCS Email Address*

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