Emergency Paid Sick Leave &
Expanded Family Medical Leave
Request
Part I Employee Information
Name
Department
Date of Hire
FTE
Faculty
Staff
Are you currently working on campus? Yes No
If yes, how many hours per week?
Are you currently teleworking? Yes No
If yes, how many hours per week?
Part II - Reason for Emergency Paid Sick Leave
Employee is subject to a Federal, State, or local
quarantine or isolation order.
Name of government entity:
Employee is experiencing symptoms of COVID-19 and is
seeking medical diagnosis.
Name of health care provider:
Employee has been advised by a health care provider to
self-quarantine due to concerns related to COVID-19.
Name of health care provider:
To care for an individual who is subject to a Federal, State, or
local quarantine or isolation order.
Name of government entity:
Name of individual and relationship toemployee:
To care for an individual advised by a health care
provider to self-quarantine due to concerns related to
COVID-19.
Name of health care provider:
Name of individual and relationship toemployee:
Caring for your child(ren) whose school or place of careis
closed, or childcare provider is unavailable due to
COVID-19 related reasons
Name and age ofchild(ren):
Name of school, place of care, orchildcare provider:
Part III Expanded Paid Family Medical Leave
Caring for your child(ren) whose school or place of care is
closed, or childcare provider is unavailable due to
COVID-19 related reasons.
Name and age ofchild(ren):
Name of school, place of care, orchildcare provider:
The initial 2-week period of leave is unpaid. By choosing one of the options below, I am directing the University to use the
following form(s) of paid leave in lieu of being unpaid during this initial 2-week period (not required):
Emergency Paid Sick Leave
Accrued/Paid Leave
Other:
By signing below, I attest that no other suitable person is available to provide care for my child(ren) during the period for which I
am receiving Expanded Paid Family Medical Leave.
Employee Signature Printed Name Date
Part IV - Leave Period
Date Leave Will Commence:
Return to Work Date:
Total Days Requested:
Are you requesting intermittent leave or a reduced work schedule? Yes No
If yes, when will you be unavailable to work?
Part V - Signatures
Employee
Signature Printed Name Date
Manager
Signature Printed Name Date
Department Head/Chair
Signature
Printed Name
Date
Part VI Office of Human Resources
Request for Emergency Paid Sick Leave
Approved
Number of Days Approved:
Disapproved
If disapproved, why:
Request for Expanded Paid Family Medical Leave
Approved
Number of Days Approved:
Disapproved
If disapproved, why:
Signature
Printed Name
Date
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome