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).