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.

 
 
 
 
 

Overtime is defined as over 40 hours in a workweek.

 
 
 

Choose how long the request is for

 

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

 
mm/dd/yyyy
 

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

 
 

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.

 
 

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

 

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

 
 

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

 

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.

Drop your files here