Patricia Keppler, Personnel & Safety Director
Leana Testani, Assistant Director of Personnel & Safety
City Hall ▪ 38 Hawley Street ▪ Binghamton, NY 13901 ▪(607) 772-7008 ▪www.binghamton-ny.gov
Department of Personnel and Safety
Employee Request for Emergency Paid Sick Leave under FFCRA (as of 3/28/20)
I am requesting Emergency Paid Sick Leave under the Families First Coronavirus Response Act (FFCRA):
A. Dates. I request leave for the following dates: __________________________;
B. Certification. I certify that I am unable to either work or telework from home based on the following Qualifying
Reason(s) below: [Initial the Qualifying Reasons that apply.]
_____ (1) The employee is subject to a Federal, State, or local quarantine or isolation order related to COVID–19.
_____ (2) The employee has been advised by a health care provider to self-quarantine due to concerns related to
COVID–19.
_____ (3) The employee is experiencing symptoms of COVID–19 and seeking a medical diagnosis.
_____ (4) The employee is caring for: an individual who is subject to an order as described in subparagraph (1); or an
individual in self-quarantine as described in paragraph (2).
_____ (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 child care provider of such son or daughter is unavailable, due to COVID–
19 precautions.
_____ (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.
C. Documentation.
1
I have provided the following documents in support of my request [List and Attach]:
________________________________________________________________________
Note: If you are eligible for Expanded FMLA under the FFCRA, you must provide additional documentation
required by the FMLA.
2
Signature: ______________________________ Date: ____________, 2020
Name:
1
Per US DOL: “If one of your employees takes paid sick leave under the Emergency Paid Sick Leave Act, you must require your
employee to provide you with appropriate documentation in support of the reason for the leave, including: the employee’s name,
qualifying reason for requesting leave, statement that the employee is unable to work, including telework, for that reason, and the
date(s) for which leave is requested. Documentation of the reason for the leave will also be necessary, such as the source of any
quarantine or isolation order, or the name of the health care provider who has advised you to self-quarantine.”
2
Per US DOL: “If one of your employees takes expanded family and medical leave to care for his or her child whose school or place
of care is closed, or child care provider is unavailable, due to COVID-19, under the Emergency Family and Medical Leave Expansion
Act, you must require your employee to provide you with appropriate documentation in support of such leave, just as you would for
conventional FMLA leave requests.”
