FFCRA FMLA Request Form
University of Central Oklahoma
Human Resources
Name:
Hire Date:
Cell Phone:
Campus Extension:
Email Address:
Department Name:
Supervisor Name:
Full-time Employee Part-time Staff Student Adjunct
This request is for my in ability to work or telework because I am caring for a child whose school or place
of care is closed (or child care provider is unavailable) for reasons related to COVID-19; or
a. Submit this form and:
i. Proof of your child’s enrollment in an Oklahoma public, charter or virtual school or;
ii. Notice of closure due to COVID-19 and proof of your child’s enrollment in private school or
daycare facility
I am requesting leave that is: Full-time Intermittent
I understand that the expanded protection only applies to care for a biological child, stepchild, adopted
child or child placed in care under foster or court order under age 18 and I may be asked to provide
documentation supporting the established relationship
I understand that it is my responsibility to submit leave time in Paycom. If I do not submit leave under the FFCRA
FMLA expansion, I will not be paid.
Employee Signature
Date
