Covid 19 – Pike County School System

EMERGENCY PAID SICK LEAVE REQUEST FORM FOR COVID-19-RELATED LEAVE

Effective for requests made on or after April 1, 2020, through December 31, 2020.

The Families First Coronavirus Response Act (“FFCRA”), which became effective on April 1, 2020, provides employees with access to emergency paid sick leave (“EPSL”) for certain leave requests related to the COVID-19 pandemic. EPSL is available for immediate use by qualifying employees. Full-time employees are eligible for up to 80 hours of EPSL. Part-time employees are eligible for EPSL in an amount equal to the number of hours the employee works, on average, over a two-week period. All paid leave under the Act is subject to the provisions outlined below. Employees should contact their supervisors or Human Resources Department with any questions.

Do not report to work if you have been diagnosed with COVID-19, are exhibiting symptoms of COVID-19, or if you have been in direct contact (within six feet) of an individual with a confirmed case of COVID-19.

Date *

Employee ID *

Employee Name *

Employee Title/Position *

School/Department *

Name of Employee's Supervisor *

Date of Leave Requested (From) *

Date of Leave Requested (To) *

I would like to request EPSL for the following reason(s): *

I am subject to a federal, state, or local quarantine or isolation order related to COVID-19
I have been advised by a health care provider to self-quarantine because of COVID-19
I am experiencing symptoms of COVID-19 and will be seeking a medical diagnosis;
I am caring for an individual who is subject to a quarantine or isolation order or has been advised to self-quarantine as described above
I am caring for a son or daughter of such employee if the school or place of care of the son or daughter has been closed, or the child care provider of such son or daughter is unavailable, due to COVID–19 precautions; and/or
I request to utilize my accrued leave to supplement any reduced compensation for this leave period, leave will be utilized as outlined in Pike BOE policy.

You will be required to provide information or documentation to support your request for emergency paid sick leave as follows. Complete the section that applies to the reason for your leave.

Leave due to a government-issued quarantine or isolation order. Name of the issuing government agency for the quarantine or isolation order:

Leave due to illness OR a health care provider’s advice to self-quarantine. Name of the health care provider advising me (or the individual I am caring for) to self-quarantine:

Written documentation is available:

Yes
No

Leave to care for an individual who is subject to a quarantine or isolation order or has been advised to self-quarantine. Name and relationship of the individual who I am needed to care for:

Leave due to a school or place of childcare closed due to COVID-19. Name, phone number and address of school or place of care:

Name and age of child or children I need to care for:

I attest that no other suitable person is available to care for the child or children during the requested leave period.

Checkbox *

I attest that the above information is accurate and complete to the best of my knowledge.

Please enter initials *

Date *