Emergency Paid Sick Leave Act
Request Form
Lamar State College Port Arthur
Name: Date:
Title: Department:
Reason for request (Select only one):
Quarantine - Two Weeks (up to 80 hours) of paid sick leave at employee’s regular rate of
pay where employee is unable to work because the employee is quarantined (pursuant to
Federal, State, or local government order or advice of a health care provider), and/or
experiencing COVID-19 symptoms and seeking a medical diagnosis.
Care for an Individual - Two Weeks (up to 80 hours) of paid sick leave at two-thirds the
employee’s regular rate of pay because the employee is:
unable to work because of a bona fide need to care for an individual subject to quarantine
(pursuant to Federal, State, or local government order or advice of a health care provider),
or
to care for a child (under 18 years of age) whose school or child care provider is closed or
unavailable for reasons related to COVID-19, and/or the employee is experiencing a
substantially similar condition as specified by the Secretary of Health and Human Services, in
consultation with the Secretaries of the Treasury and Labor.
Please supply the following documentation to your supervisor:
Quarantine: Please provide some type of doctor’s excuse, if available. If not available, please provide
reasoning:
Care for an individual: For a quarantined individual, please provide some type of doctor’s excuse if
available. For Child Care, please provide a posting, a notice, or some other type of formal note from the
school/child care provider stating the closure.
Employee Signature: ___ _____________________________ Date: _________________
Supervisor Signature: _____________________________ ___ Date: _________________
Human Resources Approval: _______________________ ___ Date: _________________
Retain a copy of this form in your departmental files and forward a copy, along with any supporting
documents, to Human Resources.
