Emergency Paid Sick Leave and Emergency
Family Medical Act Request
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____________________________________ _________________________________
Employee Name (please print) Date
Please mark below if you are invoking leave related to the Families First Coronavirus Response
Act of 2020.
Emergency Paid Sick Leave
I am invoking a leave request under the Emergency Paid Sick Leave provision. I understand that if I am
employed full-time I will be able to utilize a total of 80 hours for the selected reason below. If I am a
part-time employee the number of hours available will be based on my hours agreed on the
employment agreement.
1. I am subject to a Federal, State or local quarantine order or isolation order related to COVID-19.
2. I have been advised by a healthcare provider to self-quarantine due to COVID-19.
3. I am experiencing the symptoms of COVID-19 and seeking a diagnosis.
4. I am caring for an individual subject to or advised to quarantine or isolate.
5. I am caring for a child whose school or daycare is closed or unavailable due to COVID-19.
6. I am experiencing substantially similar conditions as those specified by the Secretary of Health
and Human Services in consultation with the Secretaries of Labor and Treasury.
I understand that for reasons 1, 2 and 3 I will be compensated at a maximum of $511 per day, not to
exceed a total of $5,110 for the duration. For reasons 4, 5 and 6 I will be compensated a maximum of
$200 per day, not to exceed a total of $2,000 for the duration.
Emergency Family Leave Act
I am invoking pay from the Emergency Family Leave Act
I am invoking this leave as I am unable to work or telework due to the need to care for my child,
under the age of 18, due to the closure or is unavailable due to public health emergency, of the child’s
school or childcare.
I understand that the first 10 days are unpaid and I can use my personal, sick or annual leave for this
time. After the first 10 days I will be paid 2/3 of my wages not to exceed $200 per day for a total of 10
weeks. The max compensation for the 10 weeks will not exceed $10,000.
________________________________________________ __________________________________
Employee Signature Date
Submit this form to Human Resources or HR@coconino.edu. Please call (928) 226-4280 regarding any
questions.
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