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