RESEARCH CORPORATION OF THE UNIVERSITY OF HAWAII
CONFIDENTIAL APPLICATION FOR
EMERGENCY PAID SICK LEAVE (EPSL)
(Effective from April 1, 2020 through December 31, 2020 for Working Employees)
INSTRUCTIONS: You must complete this application form to determine your qualification for EMERGENCY PAID SICK LEAVE (EPSL). If
approved this form must be uploaded as an attachment to your eTimesheet or submitted with your hardcopy timesheet for the pay period(s)
in which the leave was taken to the RCUH Human Resources Department. Email this document to
RCUH_Benefits@rcuh.com
Employee Name (Last, First): __________________________ ID No. _________ Date: __________
Contact Information Phone: _______________________ Email: _____________________________
Employee Category: (check box): Regular Student Temporary Intermittent
Check the applicable box below
*1. I am subject to a federal, state or county quarantine or isolation order related to COVID-19.
*2. I have been instructed by a healthcare provider to self-quarantine due to concerns related to
COVID-19. Name of healthcare provider/supporting document: __________________________
*3. I am experiencing symptoms of COVID-19 and seeking a medical diagnosis. (Employee must
complete and attach the RCUH B-11EFML Form)
*4. I am caring for an individual who is subject to an order as described in 1 or 2 above.
unavailable) due to COVID-19 or related reasons.
**5. I am caring for my child whose school or place of care is closed (or my child’s care provider is
Name of Child who is a legal dependent
Name of School, place of care provider
Employee signature certifying there is no
other suitable person to care for the child
during the period of EPSL and/or EFML
6. I am experiencing other substantially-similar condition specified by the U. S. Department of
Health & Human Services. Attach an explanation of circumstances.
*Provide name of the governmental entity ordering quarantine or the name of the health care professional advising self-quarantine, and, if
the person subject to quarantine or advised to self-quarantine is not the employee, that person’s name and relation to the employee.
**In the case of a leave request based on a school closing or child care provider unavailability, the statement from the employee should
include the name and age of the child (or children) to be cared for, the name of the school that has closed or place of care that is
unavailable, and a representation that no other person will be providing care for the child during the period for which the employee is
receiving family medical leave and, with respect to the employee’s inability to work or telework because of a need to provide care for a child
older than eighteen during daylight hours, a statement that special circumstances exist requiring the employee to provide care.
APPROVED/DISAPPROVED:
___________________________________________ ____________________
Director of Human Resources Date
cc: Employee & Personnel File (to be attached to eTimesheet or Hardcopy timesheet)
RCUH Form D-48EPSL (04/01/2020, rev. 04/02/2020)
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signature
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