HR – FFCRA (Families First Coronavirus Response Act)

Date

Employee First Name *

Employee Last Name *

Email *

Please select the leave you are requesting

Emergency Paid Sick Leave

Expanded Family Medical Leave

Emergency Paid Sick Leave (April 1, 2020 - December 31, 2020)

Dates Requested and Hours Each Day *

Total Hours Used/Requested *

Qualifing reasons for leave related to Covid-19 *

1. Is subject to a federal, state or local quarantine or isolation order.

2. Has been advised by a health care provider to self-quarantine.

3. Is experiencing symptoms associated with COVID-19 and is seeking a medical diagnosis.

4. Is caring for an individual subject to a quarantine or isolation order.

5. Is caring for a child whose school or place of care is closed or unavailable due to coronavirus-related reasons.

6. Is experiencing any other substantially similar condition specified by the U.S. Department of Health and Human Services. The agency has not specified any other substantially similar condition as of yet.

Please give a statement of why you are not able to work or telework because of the reason selected above. *

Name of the government entity that issued the quarantine or isolation order *

Provide the name of the health care provider making the quarantine recommendation because of the reason selected above. *

Government entity that issued the quarantine or isolation order or the name of the health care provider who advised the individual to self-quarantine because of the reason selected above. *

Name of person being quarantined *

What is your relationship to the individual *

Spouse

Child

Other

*

First Name of the child being cared for *

Last Name of the child being cared for *

The name of the school, place of care or child care provider that closed or became unavailable to care for the child because of coronavirus reasons *

Please provide a statement representing that no other suitable person is available to care for the child during the period of requested leave *

Signature *

Clear

Expanded Family Medical Leave Form

Start date of leave *

End date of leave *

Are you the only caregiver? *

Yes

No (If no, you are not eligible for Expanded Family Medical Leave under FFCRA)