REQUEST FOR FAMILIES FIRST CORONAVIRUS RESPONSE ACT (FFCRA) LEAVE
Eligible employees are entitled under the Families First Coronavirus Response Act (FFCRA) to take leave for certain
reasons associated with COVID-19. Employees who are unable to work (at their regular work station or through
telecommuting) are eligible for leave through the Emergency Paid Sick Leave Act and/or Emergency Family and
Medical Leave Expansion Act. When FFCRA leave becomes leave without pay, paid leave (accrued sick, annual and/or
compensatory hours) may be substituted for the unpaid leave.
Directions: Submit this request form to the Office of Human Resources for processing, as soon as possible.
Name of Employee Employee ID#
Job Title Department
Name of Supervisor Supervisor’s Title
Mailing Address During Leave City/State Zip Code
Personal Phone Number Personal Email Address
I am requesting FFCRA Leave for this purpose:
Have been advised or experiencing symptoms associated with COVID-19 and seeking medical diagnosis;
Caring for an individual who has been advised by a health care provider to self-quarantine due to concerns
related to COVID-19;
Caring for son, daughter, or legal dependent child whose school or place of care has been closed or whose
child care provider is unavailable due to COVID-19 related reasons. A completed FFCRA School/Child
Care List Form (Form 2411/003) must be attached.
Any other substantially similar condition specified by the U.S. Secretary of Health and Human Services in
consultation with the Secretary of the Treasury and the Secretary of Labor.
I am requesting FFCRA Leave for these dates and providing a statement of inability to work or telecommute:
From: (date) To: (date)
I acknowledge that submission of this form does not imply that the leave will be approved. I understand that the
approval of FFCRA leave is subject to meeting eligibility qualifications as set forth by the U.S. Department of Labor.
_________________________________________ _________________________
Signature of Employee Date
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
For HR Office Use Only: Received by HR Staff: _______________ Date: ____________
Form 2411/002 04/2020
