Families First Coronavirus Response Act (FCCRA)
Leave Request Form
Employee Name
Date Submitted
Requested Start Date
End Date
Suggested Intermittent Leave
Schedule (if applicable)
Please Return to:
Qualifying Reasons for Leave:
Under the FFCRA, an employee qualifies for paid sick time if the employee is unable to work or telework due to a need
for leave because the employee:
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 from a health care provider;
is caring for an individual subject to a federal, state, or local quarantine or isolation order or who has
been advised by a health care provider to self-quarantine due to COVID-19 related reasons;
is caring for his/her child whose school or place of care is closed (or child care provider is unavailable) for
reasons related to COVID-19; or
is experiencing any other substantially-similar condition specified by the Secretary of Health and Human
Services, in consultation with the Secretaries of Labor and Treasury.
Is the employee unable to work or telework for the reason(s) indicated above? Please explain.
If the request is based upon a quarantine, please
include the name of the governmental entity ordering the quarantine
or the name of the health care professional advising self-quarantine.
If the quarantined person is not the employee, please provide the person’s name and relation to the employee .
If the leave request for Paid Sick Leave and/or EFMLA is based upon a school closing or child care provider
unavailability, the employee must attach a statement which includes the following:
The name and age of the child (or children) to be cared for
The name of the school or place of care that is unavailable
A statement representing no other suitable person is available to care for the child during the period for which
the employee is receiving family medical leave.
If care is need during daylight hours for a child older than fourteen, a statement that special circumstances exist
requiring the employee to provide care.
The appropriate documentation must be provided to Human Resources in whole for leave to be approved.
I certify the information provided to the employer is true and accurate:
Employee Signature Date
***Internal Use Only***
Authorized Company Representative Signature Date
___ Leave is NOT approved
Provide supporting reason for denying leave:
___ Leave is approved
Type of leave approved (check all the apply):
Emergency Family and Medical Leave Expanded Act Leave
Emergency Paid Sick Leave Act Leave for care of SELF
Emergency Paid Sick Leave Act Leave for care of OTHER