Fillable Employee Request for Expanded Family and Medical Leave (University of West Florida)

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Employee Request for Expanded Family and Medical Leave (University of West Florida)

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Employee Request for
Expanded Family and Medical Leave
updated 4/7/2020
Employees requesting Expanded FMLA (EFMLA) pursuant to the Families First Coronavirus Response Act
(FFCRA) must complete this form. You must provide as much advance notice as is reasonably practicable.
Upon completion of this form, submit it to Jamie Sprague, AVP HR at jsprague@uwf.edu. Please attach a
copy of the notice letter, website posting, or published notice indicating the closure of the facility or
school.
Employee Name:
Employee Home Address:
Email:
Home Phone Number:
Cell Phone Number:
This is a:
New Request for Leave
Request for an Extension of Leave
Anticipated Begin Date of Leave:
Expected Return to Work Date:
Reason for Leave (check all applicable) I am unable to work (or telework) for the following reasons:
I need to care for my son or daughter under age 18 because my child's elementary or secondary school
has been closed due to a public health emergency
I need to care for my son or daughter under age 18 because my child's place of care has been closed
due to a public health emergency.
I need to care for my son or daughter under age 18 because the child care provider for my son
or daughter is unavailable because of a public health emergency.
I will need (choose one):
Continuous leave
Intermittent leave
If your need for leave is intermittent, please describe the nature of your intermittent leave:
Substitution of Paid Leave: Pursuant to the FFCRA, the first 10 days of your leave is unpaid,
however you may be eligible for emergency sick leave provided through the FFCRA. In the event you
are not eligible for emergency sick leave, you are permitted to use available paid leave to cover this
period. Please indicate if you would like to use paid leave during the first 10 days of your absence (if
you are not eligible for emergency sick leave) and how many hours you plan to use.
Annual Leave (_____ Hours)
Sick Leave (______ Hours)
Other/Special Comp (______ Hours)
I cert
ify that the above information is accurate and complete. I understand that if I fail to report for work on
or before the scheduled return date indicated above or fail to contact Human Resources regarding my
absence from work beyond such scheduled date of return, my employer may take corrective action.
Employee Signature Date
Human Resources Signature Date
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Employee Request for Expanded Family and Medical Leave (University of West Florida)

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Completed 31 August 2020

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