Fillable COVID-19 EMPLOYEE LEAVE REQUEST FORM (Northwestern State University)

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COVID-19 EMPLOYEE LEAVE REQUEST FORM (Northwestern State University)

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COVID-19 EMPLOYEE LEAVE REQUEST FORM
Employee: CWID#:
NSU Email Address: Department:
Under the Consolidated Appropriations Act, 2021, if you have been employed for at least (30) days, you are eligible for up to 80 hours
of paid leave under specific circumstances. This is an extension of the paid sick leave and paid family leave outlined in the Families First
Coronavirus Response Act (FFRCA) that expired on December 31, 2020. Please refer to the EMPLOYEE RIGHTS poster found on the
Human Resources page on the Faculty/Staff intra website (https://www.nsula.edu/hr/), for specific categories and daily pay maximums.
Employees may elect to utilize sick and annual leave to supplement pay up to, but not exceeding the normal paycheck.
I wish to utilize my leave accruals to supplement my pay up to, but not exceeding my normal paycheck:
________ YES ________ NO
_____ Sick Leave (must utilize rst)
_____ Annual Leave (can only be utilized after sick leave has been exhausted)
_____ Leave Without Pay (only available when all leave has been exhausted)
I am requesting to utilize COVID-19 leave for the reason indicated below:
CATEGORY 1:
_____ I am subject to Federal, State and local quarantine or isolation order related to COVID-19; or
_____ I have been advised by a health care provider to self-quarantine related to COVID-19; or
_____ I am experiencing symptoms of COVID-19 and seeking a medical diagnosis.
CATEGORY 2:
_____ I am “at risk” (older adult or have an underlying medical condition) and, based on medical orders, must remain
out of work (documentation must be attached)
CATEGORY 3:
_____ I am caring for an individual who is subject to quarantine or isolation order related to COVID-19; or
_____ I am caring for a son/daughter whose school/place of care has been closed or provider is
unavailable; or
_____
Other (please list):___________________________________________________________________________
I am requesting COVID-19 leave beginning:_________________________________ to _________________________________
DATE DATE
_________________________________________________________________________________________________________
EMPLOYEE DATE
Please scan and email this form to Human Resources at covid19hr@nsula.edu. The original form may be delivered via inter office mail to
Human Resources, St. Denis Hall.
___________________________________________________________________________________________________________
HR/Payroll Use Only:
Employee’s daily rate of pay: ____________________
Maximum daily rate of pay based on Category: ____________________
Amount required to supplement pay: ____________________
Number of hours per pay period to supplement pay: ____________________
HR/Payroll Initials: _________
rev 1-8-2021
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COVID-19 EMPLOYEE LEAVE REQUEST FORM (Northwestern State University)

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Completed 1 February 2021

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