Fillable FMLACOVID19RequestForm FMLA COVID-19 Request Form - FINAL (03697882)

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FMLACOVID19RequestForm FMLA COVID-19 Request Form - FINAL (03697882)

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{03697882.1}
FMLA ELIGIBILITY SUPPLEMENTAL FORM
FOR COVID-19-RELATED LEAVE
Effective for such requests made on or after April 1, 2020 through December 31, 2020.
The Families First Coronavirus Response Act, enacted on March 18, 2020, increases employee
access to Family and Medical Leave Act (FMLA) leave to cover leave requests related to the
COVID-19 pandemic. As of April 1, 2020, FMLA Leave is available to all employees who have
been employed with their current employer for more than 30 days and who otherwise qualify. All
paid leave is subject to the caps outlined below. Please ask us with any questions. This Form is
supplemental in nature and need only be completed if your FMLA Leave request relates to
COVID-19 and is not covered by the other FMLA forms provided.
EMPLOYEE COVID-19 RELATED LEAVE REQUEST:
Date: __________________ Employee ID:___________________
Name (please print):
Employee Title/Position: Department:__________________________
Employee Supervisor:____________________________________________________________
____ I would like to request FMLA Leave because of a qualifying need related to a public health
emergency in accordance with the FMLA. A qualifying need related to a public health emergency
means you are unable to work (or telework) due to a need for leave to care for your son or daughter
under 18 years of age if their school or place of care has been closed, or the child care provider of
your son or daughter is unavailable, due to an emergency related to COVID–19 declared by a
Federal, State, or local authority.
Dates of Leave Requested: _______________________________________________________
This FMLA Leave, after the first two weeks, is eligible for partial pay, which is two-thirds of your
regular compensation, capped at $200 per day or $10,000 total. Compensation for FMLA Leave
taken because of COVID-19 will be determined based on the number of hours you are normally
scheduled to work. Exact compensation will be reviewed upon submission of this form and will
vary depending upon the type of leave requested. If necessary, the State may request additional
information or documentation regarding this request for leave.
PLEASE NOTE THAT EXCEPT AS STATED IN THIS FORM, ALL OTHER TERMS AND
CONDITIONS OF THE FMLA CONTINUE TO APPLY. Refer to other FMLA policies to
determine and understand such requirements.
Health care providers and emergency responders will be not be eligible for this leave.
Employee Signature: ____________________________ Date:_____________
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FMLACOVID19RequestForm FMLA COVID-19 Request Form - FINAL (03697882)

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Completed 8 June 2020

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