05/2020
V. For reasons (1), (2), or (3) above related to a quarantine order or self-quarantine advice, please
provide the following information:
A. Name of the Governmental Entity (e.g., Federal, State or local authority) ordering you to quarantine or
the name of the Health Care Provider advising you to self-quarantine:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
VI. For reason (4) above related to caring for another individual under an order or advised to self-
quarantine, please provide the following information:
A. Name of the Individual: ___________________________________________________________
B. Relation to the Employee: _________________________________________________________
C. Name the Governmental Entity or Health Care Provider advising the individual to quarantine:
______________________________________________________________________________
______________________________________________________________________________
Paid Leave Duration: Emergency Paid Sick Leave is limited to 80 hours for full-time employees (e.g., 40
hours per week) or less for part-time employees based on normally scheduled work hours per day.
Paid Leave Amount: Pending approval, employees will receive Emergency Paid Sick Leave subject to the
following limitations. For reasons (1) – (3) “Self-Care”, The University will provide paid leave calculated as
100% of your regular rate of pay multiplied by the number of hours you would otherwise be normally
scheduled to work not to exceed $511 per day and $5,110 in aggregate.
For reason (4) “Family Care”, The University will provide paid leave calculated based on two-thirds of your
regular rate of pay multiplied by the number of hours you would otherwise be normally scheduled to work,
not to exceed $200 per day and $2,000 in aggregate. At this time, employees may elect to use accrued
annual leave, sick leave and/or compensatory time to receive an additional one-third of your regular rate of
pay. However, allowance of the use of accrued leave to receive an additional one-third of your regular rate
of pay is subject to change.
I have read and understand all information contained within this Employee Statement. I hereby certify and
affirm all answers provided are accurate and understand that falsification of any information or certifications set
forth herein is grounds for employee discipline, up to and including termination.
__________________________________________________ _________________________
Employee Signature Date
Once we obtain this required documentation from you, Human Resources will inform you via email in
approximately five business days whether your ESPL request has been approved. If you have any questions,
contact the Human Resources at (256) 824-6545 or hr@uah.edu.
click to sign
signature
click to edit
![]()
