Rev. 04/1/2020 CONFIDENTIAL
City of Milwaukee DER
Employees requesting Emergency Paid Sick Leave (EPSL) pursuant to the Families First Coronavirus
Response Act (FFCRA) must complete this form. You must provide as much advance notice as is
reasonably practicable. Upon completion of this form, submit it to your Departmental FMLA leave
administrator for processing.
Employee Name: Employee ID No.:
Employee Home Address: E-mail:
Home Phone Number: Phone Number:
This is a (choose one): New request for leave Request for an extension of leave
Anticipated Begin Date of Leave: Expected Return to Work Date:
Reason for Leave (check all applicable) I am unable to work (or telework) for the following reasons:
I am subject to state, federal or local quarantine or isolation order related to COVID-19
Name of government entity ordering quarantine ______________________________
I have been advised by a health care professional to self-quarantine due to concerns related to
Name of health care provider ______________________________
I have symptoms related to COVID-19 and I am seeking a diagnosis
am caring for an individual who is subject to quarantine or has been advised to quarantine
related to COVID-19
Name of individual and relationship to employee ________________________
Name of government entity or health care provider ________________________________
I need to care for my child under age 18 because the child’s school, child care or
child care
provider is closed or unavailable because of COVID-19 and no other person will be providing care
while I use leave
Name and age of child or children _____________________________________________________
Name of school or childcare provider_______________________________________
I am experiencing other conditions substantially similar to COVID-19 as specified by HHS.
I will need (choose one): Continuous leave Intermittent leave
If your need for leave is intermittent, please describe the nature of your intermittent leave:
I certify that the above information is accurate and complete. I understand that if I fail to report for work
on or before the scheduled return date indicated above or fail to contact my Departmental Leave
Administrator regarding my absence from work beyond such scheduled date of return, I may be subject
to discipline.
Employee Signature: _______________________________________ Date: ____________
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