EPSL Request Form Rev. 04/2020 (General)
Employees requesting Emergency Paid Sick Leave (EPSL) or Emergency FMLA (EFMLA) pursuant to the Families First
Coronavirus Response Act (FFCRA) must complete this request form. You must provide as much advance notice as is
reasonably practicable. Submit your completed form to your Manager for processing.
GENERAL INFORMATION
Employee Name:
Employer: Manager’s Name:
EXPECTED DURATION OF LEAVE
First Day O Work: Expected Return Date:
REQUEST FOR LEAVE (PLEASE CHECK ALL THAT APPLY)
I am unable to work (or telework) for the following reasons and am requesting leave under the FFCRA:
1. I am subject to a Federal, State, or local quarantine or isolation order related to COVID-19.
Order Issued by:
2. I have been advised by a health care provider to self-quarantine due to concerns related to COVID-19.
Name of healthcare provider:
3. I am experiencing the symptoms of COVID-19 and seeking a medical diagnosis (provide doctor’s note if available).
4. I am caring for an individual who is subject to either number 1 or 2 of the above.
Name of individual:
Relationship to individual:
5. I am caring for my minor child(ren) because the school or place of care of my child has been closed, or
the childcare provider of my child is unavailable due to COVID-19 precautions.
Name and age of child(ren):
Name of school/daycare provider:
(initial) I represent that no other suitable person will be providing care for the child(ren) listed
above during the period for which I am receiving paid leave under FFCRA.
(initial) For any child older than 14, I certify that there are special circumstances that require
me to provide care.
I will need to take leave as follows:
For a continuous block of time (dates indicated above)
On a reduced work schedule as follows:
On an intermittent basis as follows:
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.
Additional documentation in support of your leave request may be required.
Emergency Paid Sick Leave (EPSL) and Emergency
FMLA (EFMLA) Employee Request Form
Form provided courtesy of
EPSL Request Form Rev. 04/2020 (General)
AUTHORIZATION
I am requesting leave related to COVID-19 and have read the instructions on this form including details regarding
documentation requirements and agree to provide such documentation as soon as I am able. I certify that am unable to
work (or telework) for the reasons indicated above.
I further understand that I remain responsible for my portion of the health insurance premiums and any voluntary benefits
in which I am enrolled. I agree to pay these premiums either through payroll deductions or via manual payment.
Employee Signature:
Date:
Manager Signature: Date:
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