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I, ______________________________________________ (print name), am requesting FFCRA leave from
________________ (date) to _______________ (date). I do affirm that during these dates:
Please complete all information for selected category
I am subject to a quarantine/isolation order related to COVID-19.
I have been advised by a health care provider to remain in self-quarantine due to COVID-19.
_______________________________________________ (provider’s name) at
_______________________________(provider’s phone) recommended that I maintain isolation from
___________________(date) to _____________________ (date).
I have experienced COVID-19 symptoms and am seeking a medical diagnosis.
I am caring for a family member _____________________________________(name) who is subject to a
quarantine order or has been advised by a health care provider to remain in isolation due to COVID-19.
I am caring for my child _______________________________ (name)
who was enrolled in ______________________________(school), a New Mexico Public School
located in ____________________________________(city), for the 2019-2020 school year.
who was enrolled in ______________________________(school), a daycare or private K-12 school
facility located in ________________________________(city), that closed due to COVID-19.
because my regular care provider _________________________________(name) located in
__________________________(city) is unavailable due to COVID-19.
The above information is true to the best of my knowledge. I understand that intentionally false or intentionally
misleading statements in this document are misconduct and are subject to discipline, up to and including
termination of my employment.
Signature ________________________________________ Date________________________
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