COVID-19 LEAVEREQUEST FORM
Paid Sick Leave or Paid Emergency Family and Medical Leave
DateofHire:
EmployeeName:
WorksiteEmployer:
Iam unable to work and requestaleaveofabsenceforthefollowingreason (check all that apply):
Been individually advised by a government
entity to self-quarantine due to concerns
related to COVID-19
Name of government entity:
Been advised by a health care provider to self-
quarantine due to concerns related to COVID-19
Name of health care provider:
Experiencing symptoms of COVID-19 and
seeking a medical diagnosis
Name of health care provider:
Caring for an individual subject to a quarantine
due to concerns related to COVID-19
Name of individual:
Relation to employee:
Caring for a son or daughter whose school or
place of care has been closed or the childcare
provider is unavailable to provide care due to
COVID-19 precautions
Name of child(ren):
Age of child(ren):
Name of school(s) or childcare provider(s):
Anticipateddatesofleave(provideestimateddatesifexactdatesareunknown):
Begin:
Employee's Signature: Date:
◆◆◆◆◆◆◆◆◆◆◆◆◆◆◆ TOBECOMPLETEDBYWORKSITESUPERVISOR ◆◆◆◆◆◆◆◆◆◆◆◆◆◆◆
Approved Denied
Reasonfordenial(ifapplicable):
Date:
ServantHR•10412AllisonvilleRd.Ste206•Fishers•Indiana•46038•ph317.585.1688•fx317.585.1689 RevisedApril 2020
Employee can work remotely No proof of eligibility
Other:
End:
E-mail:
Phone number:
Supervisor's Signature:
Please return completed form to info@servanthr.com.
In the case of child care, by signing below I certify that no other person will be providing care for the child during the period for
which I am receiving family medical leave and, with respect to my inability to work or telework because of a need to provide care
for a child older than fourteen during daylight hours, I certify that special circumstances exist requiring me to provide care.
