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.

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.