EMERGENCY PAID SICK LEAVE
Families First Coronavirus Response Act (FFCRA)
Employees who are unable to report to work or perform duties remotely may be granted paid sick leave under the Families First
Coronavirus Response Act for certain qualifying reasons. UWF is to provide full-time employees with up to 80 hours of paid sick leave,
and part-time employees with paid sick leave based on their normal average bi-weekly hours. These payments may be capped at two-thirds
(2/3) and/or subject to a daily maximum. Please submit completed forms to hr@uwf.edu or fax to 850-857-6030.
Employee Name (Last, First, MI):
Rcd #:
Department:
Supervisor:
Selec
t qualifying reason:
Full Payment subject to a daily maximum:
Federal, state, or local ordered quarantine or isolation related to COVID-19
Medically advised quarantine or isolation related to COVID-19 (attach medical documentation)
Experiencing symptoms of COVID-19 and seeking a medical diagnosis (attach medical documentation)
Two-Thir
ds payment subject to a daily maximum:
Providing care for someone who is subject to a federal, state, or local order to quarantine or isolate
Name of Government Entity:
Providing care for someone who is medically advised to quarantine or isolate (attach medical documentation)
Caring for a son or daughter whose school or place of care is unavailable due to COVID-19 (attach FFCRA
School/Childcare Certification Form)
Duties relating to my job/position can be performed remotely: Yes (fill out below information) No
• Description of Duties:
• I can perform % of my duties from a remote location.
I ackn
owledge that the above information is true, and that any falsification of any information may be subject to disciplinary action.
Dean/Director/Department Head Name (Print)
Dean/Director/Department Head Signature
click to sign
signature
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click to sign
signature
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click to sign
signature
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