Fillable Employee Request for Paid Sick Leave and/or Emergency (Schenectady County Community College)

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Employee Request for Paid Sick Leave and/or Emergency (Schenectady County Community College)

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The Employee Request for Paid Sick Leave and/or Emergency (Schenectady County Community College) form is 3 pages long and contains:

  • 1 signature
  • 9 check-boxes
  • 19 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Schenectady County Community College

BROWSE SCHENECTADY COUNTY COMMUNITY COLLEGE FORMS

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COVID-19 Response Team
FCCRA Request Form for Employees 1 | P a g e
Employee Request for Paid Sick Leave and/or
Emergency Family and Medical Leave (FFCRA)
(April 1, 2020-December 31, 2020)
Please complete the below request for leave pursuant to the Emergency Paid Sick Leave Act
(EPSLA) and/or the Emergency Family and Medical Leave Expansion Act (FMLEA) under the
Families First Coronavirus Response Act (FFCRA), and return to Human Resources as soon as
possible.
Name: ____________________
This is a (choose one): New request for leave Request for an extension of leave
Anticipated Start Date of Leave: ___________ Anticipated End Date of Leave: ___________
I. Reason for Leave (check all applicable) I am unable to work (or telework) for the following
reasons:
1.) I am subject to a Federal, State, or local quarantine or isolation order
related to COVID-19;
2.) I have been advised by a health care provider to self-quarantine related to
COVID-19;
3.) I am experiencing COVID-19 symptoms and seeking a medical diagnosis;
4.) I am caring for an individual subject to an order described in (1) or self-
quarantine as described in (2); or
5.) I am caring for a child under 18 whose school or place of care is closed (or
child care provider is unavailable) for reasons related to COVID-19.
A. If you selected reasons 1 or 2 above, please provide the name of the governmental entity
ordering the quarantine or the name of the health care professional advising self-quarantine.
Please also attach a copy of the quarantine order or correspondence from the health care
professional advising self-quarantine.
______________________________________________________________________________
______________________________________________________________________________
B. If you selected reason 3 above, paid leave is available only for the time you are unable to work
while you are taking affirmative steps to obtain a medical diagnosis. By signing this application
form, you are certifying and representing that you will obtain a medical diagnosis as expeditiously
as possible, and upon receipt of such diagnosis, you will promptly advise us of any need for
continued leave, and your ability to return to work.
______________________________________________________________________________
______________________________________________________________________________
FCCRA Request Form for Employees 2 | P a g e
C. If you selected reason 4 above, please provide the name of the governmental entity ordering
the quarantine or the name of the health care professional advising self-quarantine, as well as
the name of the person for whom you are providing care and their relationship to you. Please
also attach a copy of the self-quarantine order or correspondence from the health care
professional advising self-quarantine.
______________________________________________________________________________
______________________________________________________________________________
D. If you selected reason 5 above, please provide the following information:
Name(s) and Age(s) of your Child/Children: _____________________________________
________________________________________________________________________
The Name of the School/Place of Care/Child Care Provider that Closed:
_______________________________
________________________________________________________________________
Please also attach documentation indicating that the school or place of care has closed. Examples
of acceptable documentation include a notice that has been posted on a government, school, or
day care website; a notice published in a newspaper; or an email or a letter from an official of
the school, place of care, or childcare provider.
By providing the information above and signing this application form, you are certifying and
representing that no other person will be providing care for your child or children during the
period for which you are receiving leave pursuant to reason 5 above and you will be unable to
work or telework in the period of requested leave.
II. Type of Leave (choose one).
I will need: Continuous leave
I am requesting: Intermittent leave
If your request for leave is intermittent, please describe the timing and frequency of your
intermittent leave request:
______________________________________________________________________________
______________________________________________________________________________
A request for intermittent leave will be considered but may be denied by the College at its
discretion. Please note that if you are working on the College’s premises (as opposed to working
remotely from home), intermittent leave will only be considered for childcare-related reasons
(reason 5 above).
FCCRA Request Form for Employees 3 | P a g e
III. Supplementing Leave with Accrued but Unused PTO
Please note further that, if you request to take leave for reasons 4 or 5 above, this leave will be
at two-thirds your regular rate of pay. If you are granted leave for reasons 4 or 5 above, for the
first two weeks, please indicate whether you choose to supplement the two-thirds pay with your
accrued but unused paid time off, and if so, the percent you wish to supplement:
______________________________________________________________________________
______________________________________________________________________________
If you are granted leave for reason 5 above beyond two weeks under the FMLEA, you will be
required to supplement your two-thirds pay under the FMLEA with your accrued but unused
paid time off for the duration of the leave, in accordance with the College’s Family Medical
Leave Act (FMLA) Policy. Such leave credits will automatically be charged on review and
approval of your request. Please note that your use of FMLEA leave for reason 5 beyond two
weeks will be reduced by any FMLA leave you have taken within the applicable 12-month look
back period. Please indicate whether you have taken any FMLA leave within the past 12-month
period, and if so, the amount of the FMLA leave taken:
______________________________________________________________________________
______________________________________________________________________________
IV. Certifications
I certify that, for each of the days that I request leave, I am unable to telework because of one
of the 5 reasons listed above.
I certify that the above information is accurate and complete:
Employee Signature: _______________________________________ Date: ____________
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Employee Request for Paid Sick Leave andor Emergency (Schenectady County Community College)

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Completed 3 February 2021

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