05/2020
V. For requesting leave related to caring for your child(ren) due to a school closing or child care
provider unavailability, please provide the following information:
I hereby certify and affirm that my child(ren) under the 18 years of age attend the below listed school/place of
care, said school/place of care is closed, or the childcare provider is unavailable, due to a public health
emergency, specifically, COVID-19, and I am the only person providing care for the child(ren) because no
other individual is present and available to care for them.
Child Name Child Age School / Place of Care
If one of the child(ren) listed above is 14 years of age or older, provide a brief description of the special
circumstances that exist requiring you to provide care:
______________________________________________________________________________________
______________________________________________________________________________________
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. Family
Medical Leave, including the expansion for childcare, is limited to 12 weeks per rolling 12-month period.
Paid Leave Amount: Pending approval, 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. In no event will paid leave exceed $200 per day and $2,000 in aggregate for Emergency
Paid Sick Leave (EPSL), or $200 per day and $10,000 in aggregate for Expanded Family Medical Leave
(EFML). The first 10 days of EFML are unpaid. Employees may use accrued annual leave, sick leave and/or
compensatory time to receive an additional one-third of your regular rate of pay for either leave type.
Employees may also use paid leave for the 10 days of unpaid EFML.
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 all required documentation from you, Human Resources will inform you via email in
approximately five business days whether your leave request has been approved. If you have any questions,
contact Human Resources at (256) 824-6545 or email uah.hr.edu.
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