Fillable FFCRA Guidance And Employee Leave Request Form (Western Carolina University)

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FFCRA Guidance And Employee Leave Request Form (Western Carolina University)

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Families First Coronavirus Response
Act (FFCRA) – Guidance and
Employee Leave Request Form
• About FFCRA
• Employee
Responsibilities
• Pay Rates and
Documentation
• Supervisor
Responsibilities
• Employee
Leave Request
Form
• Employee
Rights Poster
Families First Coronavirus Response Act (FFCRA) – Guidance and Employee Leave Request Form
The Families First Coronavirus Response Act (FFCRA) was signed into law March 18, 2020. The FFCRA, effective May 1,
2020 through December 31, 2020, includes two additional types of leave for employees impacted by COVID-19: Emergency
Paid Sick Leave and Family and Medical Leave (EFMLA). Each type of paid leave has specific eligibility requirements and
overall restrictions on the total amount of pay an employee may receive when taking leave. Note that FFCRA leave is
different from the UNC System COVID-19 Paid Administrative Leave that was implemented March 16, 2020.
Emergency Paid Sick Leave Act (EPSL)
The Emergency Paid Sick Leave Act provides up to 80 hours of paid sick leave to eligible employees under any of
six qualifying reasons related to COVID-19.
Emergency Family and Medical Leave Expansion Act (EFMLA)
The Emergency Family and Medical Leave Expansion Act (EFMLA) expands the federal Family and Medical Leave
Act to provide leave for eligible employees who are unable to work or telecommute as a result of having to care
for the employee's child due to a COVID-19 related closure of a school or childcare center.
Both types of paid leave provisions take effect May 1, 2020, and both expire Dec. 31, 2020.
NOTE: The leave provisions of the FFCRA are only for those eligible employees who cannot work, including
telecommuting, as a result of COVID-19. Employees should first be offered telecommuting opportunities to the maximum
extent possible and offer paid leave available to employees under the FFCRA only if telecommuting opportunities have
been exhausted. An employee cannot refuse work, unless the grounds for the request prevent the employee from
working, including telecommuting. As an example, an employee may only take paid leave due to “Federal, State, or local
quarantine or isolation orders” (the first of the six qualifying reasons) if being subject to one of these orders prevents the
employee from working. According to the Department of Labor, an employee may not take paid sick leave, if:
• the employer has work for the employee to perform,
• the employer permits the employee to perform that work from a remote location (e.g., where the employee is
self-quarantining), and
• there are no extenuating circumstances that prevent the employee from performing work.
Therefore, an employee may not take FFCRA leave simply because he or she prefers it to the telecommuting
opportunities offered by the employer. Instead, an employee may only take FFCRA leave if one of the qualifying reasons
for leave prevents the employee from performing the work offered.
For more information on the FFCRA and new leave provisions, including frequently asked questions and the US
Department of Labor’s informational poster, access the FFCRA FAQ page.
Employee Responsibilities:
Step I: Determine if you are applying for:
1. Emergency Paid Sick Leave (EPSL),
2. Emergency Family Medical Leave (EFMLA), or
3. Emergency Paid Sick Leave AND Emergency Family Medical Leave - Note: Emergency Paid Sick Leave can be used
during the first 10 days of EFMLA to provide payment during the initial 10 days of EFMLA which is not paid.
Step II: Gather documentation to support your request. Suggested documentation is in the table below. Complete and
sign the enclosed “EMPLOYEE REQUEST FOR EMERGENCY PAID SICK LEAVE (EPSL) AND/OR EXTENDED FAMILY
AND MEDICAL LEAVE (EFMLA).”
Step III: Submit the completed form to both your supervisor and to trisharay@email.wcu.edu.
Step IV: Enter your paid or unpaid leave on your leave/time sheet prior to the end of the pay period. Contact your
supervisor if you need assistance entering leave.
FFCRA LEAVE REASON AND PAY RATE
SUGGESTED DOCUMENTATION
1. The employee is subject to a Federal, State, or
local quarantine or isolation orders related to
COVID–19. (Leave provided at regular rate of pay
up to $511.00 per day.)
The name of the government entity that issued the quarantine or
isolation order to which the employee is subject and confirmation
that the employee is not required to physically report to work,
that all telecommuting options have been explored and there is
no option for telecommuting.
2. The employee has been advised by a health care
provider to self-quarantine due to concerns
related to COVID–19. (Leave provided at regular
rate of pay up to $511.00 per day.)
The name of the healthcare provider who advised self-quarantine
for COVID-19 related reasons.
3. The employee is experiencing symptoms of
COVID–19 and seeking a medical diagnosis.
(Leave provided at regular rate of pay up to
$511.00 per day.)
Confirmation of a doctor’s appointment or a written statement
from the employee that the employee is experiencing applicable
symptoms and describing the affirmative steps the employee has
taken to obtain a medical diagnosis. A statement that no suitable
arrangements can be made for the employee to telecommute.
4. The employee is caring for an individual who is
subject to an order as described in subparagraph
1 or has been advised as described in reason 2.
(Leave provided at two-thirds the employees’
regular rate of pay up to $200.00 per day.)
(1) The government entity that issued the quarantine or isolation
order to which the individual is subject or (2) the name of the
healthcare provider who advised the individual to selfquarantine,
depending on the precise reason for the request. A statement
that no suitable arrangements can be made for the employee to
telecommute.
5. The employee is caring for a son or daughter of
such employee if the school or place of care of the
son or daughter has been closed, or the childcare
provider of such son or daughter is unavailable,
due to COVID–19 precautions. (Leave provided at
two-thirds the employees’ regular rate of pay up
to $200.00 per day.)
(1) The name of the child being cared for; (2) the name of the
school, place of care, or child care provider that closed or became
unavailable due to COVID-19 reasons; and (3) a statement
representing that no other suitable person is available to care for
the child during the period of requested leave and that no suitable
arrangements can be made for the employee to telecommute.
6. The employee is experiencing any other
substantially similar condition specified by the
Secretary of Health and Human Services in
consultation with the Secretary of the Treasury
and the Secretary of Labor. (Leave provided at
two-thirds the employees’ regular rate of pay up
to $200.00 per day.)
If leave is being taken for this reason, please contact
trisharay@email.wcu.edu for additional information.
Supervisor Responsibilities:
Step I: If an employee requests this type of leave, discuss telecommuting options and flexible work arrangements to
help the employee decide if leave should be taken continuously or intermittently, or if other telecommuting options
can be arranged. Per the Governor’s executive orders, state agencies should first offer telecommuting opportunities to
employees to the maximum extent possible and offer paid leave available to employees under the FFCRA only if
telecommuting opportunities have been exhausted. If intermittent leave is a workable solution, establish and
document the intermittent/flexible work schedule. If work is available and the employee declines the work
opportunities presented, or if no telecommuting opportunities are available, please contact trisharay@email.wcu.edu
before signing this form.
Step II: Submit email approval of the request (from an approved WCU email address) with the form attached to both the
employee and TrishaRay@email.wcu.edu. To certify approval please include the following statement in the email: I have
received and reviewed the attached FFCRA request for (employee name). This email shall serve as approval and my
signature.
Questions?
If you have any questions regarding the Families First Coronavirus Response Act, please submit an inquiry to
trisharay@email.wcu.edu.
Western Carolina University EPSL/EFMLA Request Form
The federal Families First Coronavirus Response Act (FFCRA) provides Emergency Paid Sick Leave (EPSL) and Emergency Family
Medical Leave (EFMLA). To request this leave, complete the appropriate sections of the form below.
Employee Name:
ID:
Dept. Name:
Name:
Address:
Phone:
Name of Clinic/Hospital/Telemed Service:
Full Name of Individual Subject to Quarantine (if other than employee):
Relationship to Employee:
Date of Service:
Name:
Address:
Phone:
Full Name of Child Needing Care:
Child’s Age:
Full Name of Child Needing Care:
Child’s Age:
Full Name of Child Needing Care:
Child’s Age:
Full Name of Child Needing Care:
Child’s Age:
Do you plan to use accrued leave to supplement emergency leave?
Yes No
Type of Leave:
COVID-19 Leave Compensatory Leave Vacation Leave Sick Leave Bonus Leave
Other:
Employee’s Signature:
Date:
Rev. April 8, 2020 Form Page 2 of 2 CONFIDENTIAL
EMPLOYEE RIGHTS
PAID SICK LEAVE AND EXPANDED FAMILY AND MEDICAL LEAVE
UNDER THE FAMILIES FIRST CORONAVIRUS RESPONSE ACT
The Families First Coronavirus Response Act (FFCRA or Act) requires certain employers to provide their
employees with paid sick leave and expanded family and medical leave for specified reasons related to COVID-19.
These provisions will apply from April 1, 2020 through December 31, 2020.
►
PAID LEAVE ENTITLEMENTS
Generally, employers covered under the Act must provide employees:
Up to two weeks (80 hours, or a part-time employee’s two-week equivalent) of paid sick leave based on the higher of
their regular rate of pay, or the applicable state or Federal minimum wage, paid at:
• 100% for qualifying reasons #1-3 below, up to $511 daily and $5,110 total;
• 2/3 for qualifying reasons #4 and 6 below, up to $200 daily and $2,000 total; and
• Up to 12 weeks of paid sick leave and expanded family and medical leave paid at 2/3 for qualifying reason #5
below for up to $200 daily and $12,000 total.
A part-time employee is eligible for leave for the number of hours that the employee is normally scheduled to work
over that period.
►
ELIGIBLE EMPLOYEES
In general, employees of private sector employers with fewer than 500 employees, and certain public sector
employers, are eligible for up to two weeks of fully or partially paid sick leave for COVID-19 related reasons (see
below). Employees who have been employed for at least 30 days prior to their leave request may be eligible for up to
an additional 10 weeks of partially paid expanded family and medical leave for reason #5 below.
►
QUALIFYING REASONS FOR LEAVE RELATED TO COVID-19
An employee is entitled to take leave related to COVID-19 if the employee is unable to work, including unable to
telework, because the employee:
1.
2.
3.
4.
is subject to a Federal, State, or local quarantine or
isolation order related to COVID-19;
has been advised by a health care provider to self-
quarantine related to COVID-19;
is experiencing COVID-19 symptoms and is seeking
a medical diagnosis;
is caring for an individual subject to an order described
in (1) or self-quarantine as described in (2);
5.
6.
is caring for his or her child whose school or
place of care is closed (or child care provider is
unavailable) due to COVID-19 related reasons;
or is experiencing any other substantially-similar
condition specified by the U.S. Department of
Health and Human Services.
►
ENFORCEMENT
The U.S. Department of Labor’s Wage and Hour Division (WHD) has the authority to investigate and enforce compliance
with the FFCRA. Employers may not discharge, discipline, or otherwise discriminate against any employee who lawfully
takes paid sick leave or expanded family and medical leave under the FFCRA, files a complaint, or institutes a
proceeding under or related to this Act. Employers in violation of the provisions of the FFCRA will be subject to penalties
and enforcement by WHD.
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FFCRA Guidance And Employee Leave Request Form (Western Carolina University)

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Completed 1 September 2020

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