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EMERGENCY PAID LEAVE ATTESTATION & REQUEST FORM Full-Time (City University of New York)

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EMERGENCY PAID LEAVE ATTESTATION & REQUEST FORM
COLLEGE:
Full-Time and Part-Time employees may be entitled to emergency paid sick leave if they are unable to work
(or telework) because of the effects of COVID-19. The duration of leave and the percentage of pay is determined by
the Qualifying Reason for the leave.
To request Emergency Paid Sick Leave under the Families First Coronavirus Response Act (FFCRA) please complete
the following request form and attestation and submit to your human resources department with any
supporting documentation as soon as possible.
Employee Information:
Name:
Contract Title:
Empl. ID:
Department:
Supervisor Name:
Phone: Email:
Contact While on Leave: Cell Phone: _______________________________________
Home Phone: Email:
Check One: ☐Full-Time ☐ Part-Time Number of Hours Worked per Week:
Period of Leave Requested:
Leave Start Date:
Leave End Date:
Employee Attestation:
I, , am requesting the period of Emergency Paid Sick Leave above
and I am/was unable to work or telework because of the Qualifying Reason selected below:
☐ 1) I am subject to a federal, state, or local quarantine or isolation order related to COVID–19.
Name of the Government Entity that issued the quarantine or isolationorder:
Effective dates of the order:
☐ 2) I have been advised by a health care provider to self-quarantine due to concerns related to COVID–19.
Name of the Health Care Provider who provided the advice:
☐ 3) I am experiencing symptoms of COVID–19 and seeking a medical diagnosis.
Provide details regarding the need for this leave and the name of the health care provider you intend to consult
with:
☐ 4) I am caring for an individual who is subject to either number 1 or 2 above.
Name: Relation:
Name of the Government Entity that issued the quarantine orisolation order:
Name of the Health Care Provider who provided the advice:
☐ 5) I am caring for my child whose primary or secondary school or place of care has been closed, or my childcare
provider is unavailable due to COVID–19 precautions. For purposes of this section, child means a biological,
adopted, or foster child, a stepchild, legal ward, or a child of a person standing in loco parentis, who is under
18 years of age;
Name of school or place of care closed due to concerns relatedto COVID-19:
Name of child caregiver unavailable due to concerns relatedto 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.
☐ 6) I am experiencing another substantially similar condition specified by the secretary of health and human services.
Provide details regarding the need for this leave:
I understand that providing false or misleading information regarding the need for Emergency Paid Sick 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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EMERGENCY PAID LEAVE ATTESTATION & REQUEST FORM Full-Time (City University of New York)

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Completed 18 December 2020

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