April 2, 2020
Employee Name:
Employee ID:
Job Title:
Division/Department:
Classification:
Full-Time: Part-Time:
Exempt: Non-Exempt:
Supervisor Name:
Supervisor email/Ext.
Date Requested:
Date of Requested Extension (if applicable):
In accordance with Chancellor White’s March 17, 2020 message to employees of the need to telecommute as a safeguard
against the coronavirus, he acknowledged special considerations are to be given to employees age 65 or older and/or who
have a chronic medical condition(s). This form should be completed by employees who are unable to telecommute and who
are age 65 or older and/or who have a chronic medical disease/condition.
PERMISSIBLE USE OF LEAVE
I am unable to work because I have been directed by my appropriate administrator not to come to the worksite and it is not
operationally feasible for me to work remotely and I meet the following Special Consideration(s):
I AM AGE 65 OR OLDER
I
HAVE A CHRONIC MEDICAL CONDITION. [A CHRONIC MEDICAL DISEASE/CONDITION IS BORADLY DEFINED BY THE
CENTER FOR DISEASE CONTROL AND PREVENTION (CDC) AS ONE THAT IS EXPECTED TO LAST 1 YEAR OR MORE,
REQUIRES ONGOING MEDICAL ATTENTION, AND LIMITS THE ACTIVITIES OF DAILY LIVING.]
Request for Dates of Coronavirus Pandemic (COVID-19) Special Consideration - Temporary Paid Leave
Month
Dates Requested
Total Number of Hours Requested
Total Hours:
SIGNED AND AGREED BY:
To the best of my knowledge and belief, I certify that the facts stated are accurate and in full compliance with the intended
use of the Special Consideration Temporary Paid Leave granted by the Chancellor.
Employee Name: _______________________________ Signature: _______________________________ Date: ________
I
approve the use of Special Consideration Temporary Paid Leave as indicated above.
Appropriate Administrator Name: ________________________ Signature: ________________________ Date: ________
HR/Academic Personnel Designee Name: ______________________ Signature:_____________________ Date: ________
EQUEST FOR
PECIAL
ONSIDERATION
EMPORARY
AID
EAVE
ORM
Coronavirus Pandemic (COVID-19)
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