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):
☐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
I will contact the Office of Human Resources at 518-381-1218, or via email at
email@example.com to make this request.
☐A reason related to COVID-19, not included in the list above.
☐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.