2021-22 – REQUEST FORM - COVID Leave Days
Dates of Absence (specific start and end dates)
Cypress-Fairbanks ISD approved 10 COVID Leave Days to be used for absences incurred July 1, 2021
through June 30, 2022 for qualifying COVID-positive absences. This leave cannot be used intermittently.
An employee requesting use of CFISD COVID Leave must complete this form and return it to
HRLeave@cfisd.net within 3 business days in order for leave to be processed in a timely manner. Please
submit required medical documentation at the same time as this request.
CFISD COVID Leave is limited to the equivalent of 10 workdays (maximum of 80 hours) of paid leave.
I request leave for the following reason(s):
SELF
I have tested positive for COVID-19 and submitted medical documentation of lab-confirmed COVID-
positive results. Home tests are not acceptable.
CARE OF QUALIFYING FAMILY MEMBER – only for spouse, parent (not in-laws), child
I am unable to work due to a need for leave to care for a qualifying family member who has tested COVID-
positive. Lab confirmed test results documenting COVID-positive test required. Home tests are not
acceptable.
Name of family member: Relationship:
Employee Signature Date
Designation (completed by HR Department):
The employee qualifies for CFISD COVID Leave.
The employee does not qualify for CFISD COVID Leave.
For office use only:
Medical certification provided
Yes No
Processed by:
Date Processed:
