COVID-19 Response Team
Section 5 - COVID-19 Statement of College Employee Return Intentions 1 | P a g e
COVID-19 Statement of College Employee Return Intentions
Employee Name: _________________________________________________________________
Employee Contact Number (phone):
Date: _________________________________________________________________
Supervisor: _________________________________________________________________
Please be advised that I intend to return to the office as directed.
Please be advised that I will not be able to return to the office as directed due to:
A COVID-19 qualified reason, covered under the Families First Coronavirus Response Act
(FFCRA).
I will contact the Office of Human Resources at 518-381-1218, or via email at
humanresources@sunysccc.edu to make this request.
A reason related to COVID-19, not included in the list above.
Describe: __________________________________________________________
__________________________________________________________
__________________________________________________________
I request that consideration be given to an alternative that will allow me to continue
working from an alternate location.
I am requesting consideration be given to an unpaid leave of absence.