Families First Coronavirus Response Act
Emergency Expanded FMLA (COVID-19)
EMPLOYEE INFORMATION
Name:
Employee ID #:
Phone:
Department:
Division:
REASON FOR LEAVE REQUEST & ABSENCE DATES
Child(ren)’s School/Childcare Closure/Unavailability
PAY STATUS DURING THE LEAVE:
The first 2 weeks of Emergency Expanded FMLA is unpaid. Employees may choose to receive pay through the use of
AVAILABLE PAID LEAVE HOURS. Indicate your election for the first 2 weeks of Emergency Expanded FMLA:
USE AVAILABLE PAID LEAVE HOURS IN THE ORDER SPECIFIED BELOW
NOT USE ANY FORM OF AVAILABLE PAID LEAVE HOURS LEAVE AND GO INTO AN UNPAID STATUS.
Please note going into an unpaid status can have certain consequences such as the requirement to pay for the
employee’s share of health benefits out of pocket and the lack of accrual of additional leave
Please identify the number of hours you wish to use AND the priority in which you wish to use your hours.
For example, for two weeks off you can enter 40 hours vacation and 40 hours of Comp time. Put a #1 priority for Vacation and #2
priority for Comp Time. By “prioritizing” you will exhaust all time in the order preferred, if applicable. Please feel free to call your
Payroll Specialist for assistance.
Code
Description
Hours
Priority
Code
Description
Hours
Priority
635
Emergency Paid Sick Leave
041
Vacation Hours
035
Sick Leave
052
Comp/Admin Hours
061
Leave w/o Pay
048
Holiday Hours
The remaining period of Emergency Expanded FMLA (up to 10 additional weeks) is paid at 2/3’s of your regular rate
of pay with a maximum of $200 per day. Employees may choose to supplement this amount with available paid leave
hours in order to receive full pay. Note: For some employees, Federal Emergency Paid Sick Leave also has a daily cap on
compensation and employees may wish to use other available paid leave hours to supplement such amounts.
TO USE AVAILABLE PAID LEAVE HOURS TO SUPPLMENT THE DAILY PAY CAPS IN THE FFCRA IN THE ORDER
SPECIFIED BELOW
TO NOT USE ANY FORM OF AVAILABLE PAID LEAVE HOURS TO SUPPLEMENT THE DAILY PAY CAPS IN THE FFCRA
Please identify the number of hours you wish to use AND the priority in which you wish to use your hours.
Code
Description
Hours
Priority
Code
Description
Hours
Priority
635
Emergency Paid Sick Leave
041
Vacation Hours
035
Sick Leave
052
Comp/Admin Hours
061
Leave w/o Pay
048
Holiday Hours
ACKNOWLEDGEMENT
I CERTIFY THAT MY ABSENCE REQUEST IS FOR THE COVID-19 RELATED REASON STATED ON THIS FAMILIES FIRST CORONAVIRUS RESPONSE ACT
EMERGENCY EXPANDED FMLA (VOVID-19) FORM.
I UNDERSTAND THAT LEAVE TAKEN AS A RESULT OF THE COVID-19 PUBLIC HEALTH CRISIS FOR WHICH I RECEIVE PAID LEAVE UNDER THE FFCRA
OR COUNTY POLICY WILL BE COUNTED AGAINST MY ENTITLEMENTS. I ALSO UNDERSTAND THAT PROVIDING FALSE OR MISLEADING
INFORMATION ABOUT MY ABSENCE WILL RESULT IN DISCIPLINARY ACTION, UP TO AND INCLUDING TERMINATION OF MY EMPLOYMENT.
Signature:
Date:
Submission Instructions: 1) Fill out this form completely, sign, and provide a copy of it to your Manager. 2) Upload the completed copy to Workday Leave of Absence
Request for COVID-19 Leave for School/Childcare Closure.
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