Anticipated schedule of absence must be discussed with supervisor. For Intermittent or Reduced Work Schedule,
appropriate documents must be attached.
FMLA Time Used Last 12 Months:
Check One: ☐ No ☐ Yes From: To:
Employee Statement Supporting Leave
I, , provide the following information in support of my request for expanded
Family and Medical leave (complete all that apply):
Name of school or place of care closed due to concerns related to COVID-19:
Name of child caregiver unavailable due to concerns related to COVID-19:
Name and age of child or children I am needed to care for:
Name:
Age:
Name:
Age:
Name:
Age:
I, , attest that no other suitable person is available to care for my child or
children during the period of requested leave.
☐ I attest that special circumstances exist requiring my need for leave to care for a child over the age of 14.
I understand that the initial 2 weeks (10 days) of Emergency FMLA Expansion is unpaid. I elect to be paid for the first 10
days under the Emergency Paid Sick Leave Act. Check one:
☐ Yes ☐ No
I elect to substitute my accrued paid time under my employer benefits after the initial 2 weeks.
Check one: ☐ Yes ☐ No ☐ N/A
I attest that the above information is accurate and complete. I understand falsification of any information given may
lead to disciplinary action.
I understand that providing false or misleading information regarding the need for Emergency Family Medical Leave or any
Families First Coronavirus Response Act qualifying reason will be grounds for appropriate action, which could include
discipline up to and including termination of employment in accordance with applicable CUNY policies and collective
bargaining agreements.
Employee Signature: Date:
For Human Resources Use Only
HR Representative Name:
HR Representative Signature: Date:
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