EMERGENCY PAID SICK LEAVE REQUEST FORM
FOR COVID-19-RELATED LEAVE
Effective for requests made on or after April 1, 2020 through December 31, 2020.
The Families First Coronavirus Response Act (“Act”), enacted on March 18, 2020, provides employees
with access to emergency paid sick leave (“EPSL”) for certain leave requests related to the COVID-19
pandemic. As of April 1, 2020, EPSL is available for immediate use by qualifying employees. Full-time
employees are eligible for up to 80 hours of EPSL. Part-time employees are eligible for EPSL in an amount
equal to the number of hours the employee works, on average, over a two-week period. All paid leave
under the Act is subject to the provisions outlined below. Employees should contact their supervisors or
human resources departments with any questions.
EMPLOYEE EPSL REQUEST:
Date: _________________________ Banner ID*: ___________________________________
Name (please print): _____________________________________________________________
Employee Title/Position: ____________________ Department ___________________________
Employee Supervisor: ____________________________________________________________
I would like to request EPSL for the following reason(s) (check all that apply):
_____ (1) I am subject to a federal, state, or local quarantine or isolation order related to
COVID-19;
_____ (2) I have been advised by a health care provider to self-quarantine because of COVID-
19;
_____ (3) I am experiencing symptoms of COVID-19 and am seeking a medical diagnosis;
_____ (4) I am caring for an individual who is subject to an order as described in subparagraph
(1) or has been advised as described in subparagraph (2).
_____ (5) I am caring for a biological, adopted, or foster child, a stepchild, a legal ward, or a child
of a person standing in loco parentis, under 18 years of age or who is 18 years of age
or older but is incapable of self-care due to a disability, whose school or place of care
is unavailable, due to COVID19 precautions; or
_____ (6) I am experiencing any other substantially similar conditions as specified by the
Secretary of Health and Human Services, in consultation with the Secretaries of Labor
and Treasury.
Dates of Leave Requested: __________________________ to ___________________________
{03697876.1}
COMPENSATION PROVISIONS
1. The employee will be compensated for EPSL at their regular rate, up to $511 per day,
where leave is taken for reasons (1), (2), and (3) above (own illness or quarantine)
2. The employee will be compensated for EPSL 2/3 their regular rate, up to $200 per day,
where leave is taken for reasons (4) or (5) above (care for others or school closures).
3. It is unlawful for any employer to require the employee to find a replacement, discharge,
discipline, or in any other manner discriminate against any employee taking leave in
accordance with this Act.
_____ I request to utilize my accrued leave to supplement the reduced compensation for this
leave period. I agree that my leave will be utilized as outlined below unless other
arrangements have been documented in an email from Payroll.
If this leave request is for reasons 1-3, the leave will be applied in the following order
of availability: sick leave, accrued compensatory time, vacation leave.
If this leave request is for reasons 4-6, the leave will be applied in the following order
of availability: accrued compensatory time, vacation leave, sick leave.
Employee Signature: _____________________________________________ Date: ________________
Please return this form to:
hr@uco.edu
If the expected duration of the leave changes or if you have any questions, please contact Payroll@uco.edu
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