Fillable EMERGENCY PAID LEAVE REQUEST You must complete ALL (Ramsey County)

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EMERGENCY PAID LEAVE REQUEST You must complete ALL (Ramsey County)

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Page | 1
N:FMLA/Expanded FMLA/EFMLEA Forms
Employee Name (Last, First, MI) Empl ID
Primary Phone:
Email to contact you:
Department & Work Location Current Job Title Date of Hire Current Supervisor
Typical Hours
worked per day
IMPORTANT INSTRUCTIONS – READ CAREFULLY:
1. ALL Employees are expected to continue to work (telework where available) when possible.
2. Most employees may be eligible for emergency paid leave (Emergency Paid Sick Leave (EPSLA) and Emergency Paid
Family & Medical Leave (EFMLEA) benefits) under FFCRA. Use this form to request these benefits.
3. Read ”Guidance for Exposure to COVID-19 and Leave Time as Determined by FFCRA” for more detailed information.
4. All employees may be eligible for EPSLA benefits. Complete the form (Parts A, B, C & D) in full, review it with your
supervisor to obtain approval, and submit to CONTACTHR@CO.RAMSEY.MN.US for processing. HR will notify you
whether you are approved for this leave.
5. County emergency and health care workers working in the following facilities are ineligible for EFMLEA:
Adult Detention Center, Correctional Facility, Juvenile Detention Center, Care Center, Detoxification Center, Emergency
Communications Center, Lake Owasso Residence, Medical Examiner and Sheriff’s Offices.
EMPLOYEES WORKING AT THESE FACILITIES SHOULD NOT REQUEST EFMLEA, IT WILL BE DENIED.
Employees working at these facilities are eligible for the following:
• Are eligible for up to two weeks/80 hours of (EPSLA) (complete form as instructed above).
• Are eligible for the County’s PEPEL leave.
I am requesting (CHECK ONE)
DISCUSS WITH YOUR SUPERVISOR PRIOR TO SUBMISSION.
My leave begins (no earlier than 4/1/20 ) and expected
return dates are:
☐ Continuous Leave
Continuous leave to start:
Return to work date:
☐ Intermittent Leave; Detail of proposed schedule:
Intermittent leave to start:
Return to work date:
☐ I am currently working/teleworking (including redeployment assignments).
☐ If you are no longer able to work, tell us why:
Employee Signature
Date
☐ Type in name:
By checking the above box, I certify and authorize this request for leave in its entirety for a covered reason under the Families First Coronavirus
Response Act (FFCRA) as stated below. I agree to provide additional documentation to support this leave if requested and I acknowledge: 1) If I
don’t comply, I may be denied this leave; 2) I am responsible to follow department call-in procedures; and 3) I may be subject to discipline, up to
and including termination of employment for falsifying my need for leave under the FFCRA.
Supervisor Signature
Date:
☐ Type in name:
By checking the above box, I certify I have reviewed this request and approve the proposed intermittent or continuous schedule.
PART A:
EMERGENCY PAID LEAVE REQUEST
You must complete ALL highlighted parts of your request, as incomplete request may be denied.
☐ I am requesting an extension for leave due to school closing/childcare. I have updated the extended begin/return dates above.
Reason:
Reset Form
Page | 2
N:FMLA/Expanded FMLA/EFMLEA Forms
Employee Name (Last, First, MI)
Empl ID
☐
PART B: Check here if you are requesting EMERGENCY PAID SICK LEAVE
(maximum of 80 hours based on full-time status)
Select one or more of the following reasons for why you are unable to work or telework on or after April 1, 2020.
You must complete ALL highlighted parts of your request, as incomplete request may be denied.
☐
1.
☐ State of MN as of 3/28/20 ☐ State of WI as of 3/25/20 Other
2.
I have been advised by a health care provider to self-quarantine due to concerns related to COVID–19. Please provide
date, name and address of health care professional:
3. I am experiencing symptoms of COVID–19 and seeking a medical diagnosis. Please provide date, name and address of
4.
I am caring for an individual who is subject to either number 1 or 2 above. Complete information in 1 or 2 above.
Provide Full Name and relationship to employee:
☐
5.
☐ I certify that no other person will be providing care for the child during the period for which I am receiving paid leave.
☐ Special circumstances exist that require that I provide care for a child older than fourteen. Describe these
circumstances:
Names and ages of children: Names of school/places of care that are closed:
☐
6.
I am experiencing any other substantially similar condition specified by the Secretary of Health and Human Services in
consultation with the Secretary of the Treasury and the Secretary of Labor.
☐
PART C: Check here if you are requesting EMERGENCY PAID FAMILY & MEDICAL LEAVE
(maximum of 10 weeks in addition to Emergency Paid Sick Leave based on full-time status)
An employee may be eligible to receive both Emergency Paid Sick Leave and Emergency Paid Family and Medical Expansion Leave if
caring for a child due to a school closure or childcare provider unavailability due to COVID–19.
I am caring for a child due to a school closure or childcare provider unavailability due to COVID–19.
Select applicable statement:
☐ I certify that no other person will be providing care for the child during the period for which I am receiving paid leave.
☐ Special circumstances exist that require that I provide care for a child older than fourteen. Describe these circumstances:
Names and ages of children: Names of school/places of care that are closed:
I am subject to federal, state, or local quarantine or isolation order related to COVID–19. NOTE: As Ramsey County is
open for business, county employees are generally exempted from this provision; if an employee selects this alternative,
provide the reason for this request here:
Select each applicable statement:
I am caring for a child due to a school
closure due to COVID–19. Date school year ends:
☐
Select one of the following:
AS OF DATE:
☐
☐
health care professional:
☐
Describe the circumstances related to COVID-19:
☐ I am caring for a child due to unavailability of child care specifically due to COVID–19.
Describe the circumstances related to COVID-19:
Provide dates of closure:
to
You must complete ALL highlighted parts of your
request, as incomplete request may be denied.
Page | 3
N:FMLA/Expanded FMLA/EFMLEA Forms
Employee Name (Last, First, MI)
Empl ID
PART D: SUPPLEMENTAL PAY
Instructions: An employee can choose to supplement their wages to 100%; to do so, complete the following section.
1. Indicate choices in rank order (e.g. 1, 2, 3, 4); employee does not have to use all these choices, they are at employee
discretion.
Pandemic Emergency Paid Employee Leave
(
PEPEL) time is required to be used first.
2. Human Resources will review eligibility for these benefits as well as employee balances as of the last payroll before
instructing department payroll contacts how to assign use of accrued time.
☐
YES, I wish to be paid equal to 100% of my wage. Use PEPEL and
my accrued paid leave to supplement my wages to 100% for the
duration of my leave in the following order, beginning with #2.
NO, I do not want to use PEPEL or accrued paid
leave to supplement my wages to 100%
• For reasons 1, 2, & 3 the first two weeks of federal Emergency Paid Sick Leave is paid at 100% up to $511 daily; Thereafter to
receive up to 100% of pay, an employee would need to supplement with their PEPEL and accrued leave balances. **
• For reasons 4, 5 & 6 the first two weeks of federal
Emergency Paid Sick Leave
is paid at 2/3 an employee’s wage up to $200
daily. Thereafter to receive up to 100% of pay, an employee would need to supplement with their PEPEL and accrued leave
balances. **
• For only reason 5, may I request up to an additional 10 weeks of federal
Emergency Paid Family and Medical Expansion Leave
paid at 2/3 my wage up to $200 daily. Thereafter to receive up to 100% of pay, an employee would need to supplement with
their accrued leave balances. **
①
PEPEL will be used before all other accrued balances
Compensatory Time
Accrued Sick Leave
Holiday Reserve
Accrued Vacation
Approved Sick Leave Advance
Floating Holiday
Approved Vacation Advance
NOTE: when all the above have zero balances, an unpaid leave may be available.
**See Guidance for Exposure to COVID-19 and Leave Time as determined by FFCRA.
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EMERGENCY PAID LEAVE REQUEST You must complete ALL (Ramsey County)

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Completed 20 August 2020

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