Fillable Emergency Paid Sick Leave Act & FML Expansion (University of Baltimore)

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Emergency Paid Sick Leave Act & FML Expansion (University of Baltimore)

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Emergency Paid Sick Leave Act & FML Expansion Request Form (COVID-19)
Employee Name:______________________________ Empl ID:__________ Date:____________
Department:_________________________________ Status: ☐ Faculty ☐ Staff ☐ Student
1. I am requesting emergency paid leave (up to 10 work days) at full pay due to:
☐ a government issued quarantine or isolation order for myself
☐ advised to self-quarantine by a healthcare provider for myself
☐ to obtain a medical diagnosis after experiencing symptoms of COVID-19 for myself
2. I am requesting emergency paid leave (up to 10 work days) at 2/3 pay to:
☐ care for an individual that is subject to a government quarantine or isolation order or has been advised by a
health care provider to self-quarantine
☐ care for a child subject to a school or daycare closure
I choose to supplement my 2/3 pay for the above care reason with the following leave (not required):
☐ vacation
☐ sick
☐ personal
☐ other __________________
3. I am requesting FMLA Expansion coverage (up to 12 weeks) to:
☐ care for a child if their school or place of care has been closed or the child care provider is unavailable due
to a COVID-19 related emergency.
I choose to use the following leave (specify order in which leave is to be used, if applicable):
☐ vacation _____________
☐ sick_________________
☐ personal_____________
☐ other __________________
Leave will be taken:
☐ intermittently (specify leave hours per week) _____________
☐ full time
4. Name and address of healthcare provider or school/childcare provider:
EMPLOYEE AUTHORIZATION
I understand that I must provide medical documentation from a healthcare provider, if it is due to a medically
ordered quarantine, isolation or medical directive to obtain a medical diagnosis for myself or to care for an
individual that is subject to a quarantine or isolation order. Government issued quarantine or isolation orders do
not required medical documentation. I understand that all information obtained during this process will be
maintained and sued in accordance with the confidentiality requirements.
Employer Name and Signature:___________________________________________ Date:___________
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SUPERVISOR ACKNOWLEDGEMENT
I acknowledge that this employee has notified me that they are seeking approval of Emergency Paid Sick Leave Act
& FML Expansion. I have reviewed any required documentation and approved the request.
Supervisor Name and Signature:__________________________________________ Date:__________
HUMAN RESOURCES ACKNOWLEDGEMENT
I acknowledge that this employee has notified me that they are seeking approval of Emergency Paid Sick Leave Act
& FML Expansion. I have reviewed any required medical documentation and approve the request.
HR Approver Name and Signature:________________________________________ Date:___________
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Emergency Paid Sick Leave Act & FML Expansion (University of Baltimore)

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Completed 24 July 2020

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