FFCRA CHILD-SCHOOL LIST FORM
FAMILIES FIRST CORONAVIRUS RESPONSE ACT (FFCRA)
DIRECTIONS: Attach this completed form to the Request for FFCRA Leave Form
(Form 2411/002) IF requesting FFCRA Leave due to caring for a son, daughter, or a
legal dependent child whose school or place of care has been closed or whose child care
provider is unavailable due to COVID-19 related reasons.
EMPLOYEE NAME: _________________________________________
JOB TITLE: ______________________________________________
SUPERVISOR’S NAME: _____________________________________
SUPERVISOR’S JOB TITLE: __________________________________
I certify that I am the parent or legal guardian of the child/children listed above AND the child/children’s
school or place of care has been closed or child care provider is unavailable due to COVID-19 reasons.
Employee’s Signature: _____________________________ Date: ____________
Form 2411/003 (4/2020)
Child’s Name
*For children over 14, describe
special circumstances.
School/Childcare Facility
