Families First Coronavirus Response Act (FFCRA)
Certification Request Letter
Employee Name: ___________________________________________
Employee ID Number: _______________________________________
Employee Position Title: ______________________________________________________________________
Employee Department and Division: ____________________________________________________________
Employee Email Address: _____________________________________
Dear Employee,
Thank you for alerting us to your need for leave. We ask that you return this form to us, along with documentation as
requested below, so that we can assess your leave and pay request.
I am requesting two weeks of paid sick time for one of the reasons listed below. I understand that sick time is paid at
100% for reasons (1) (3) and capped at $511 per day. I understand that sick time is paid at two-thirds for reasons
(4) (6) and capped at $200 per day. In both cases, aggregate caps apply for the total ($5110/$2000).
I understand that I have a right to paid sick time under the Families First Coronavirus Response Act (FFCRA), but I am
choosing not to use the paid sick time and would prefer to use:
Annual Leave
Sick Leave
Bonus Leave
Unpaid Leave
Other (please specify): _______________________
Dates of Leave Requested: ______________ to ____________. If requesting a reduced schedule or intermittent leave,
please provide details in the space below.
Please select your reason for being unable to work or telework:
1. I am subject to a Federal, State, or local quarantine or isolation order related to COVID-19.
Name of agency issuing order: ____________________________________________________________
2. I have been advised by a health care provider to self-quarantine for reasons related to COVID-19.
Name of healthcare provider issuing advice: _____________________________________________
3. I am experiencing COVID-19 symptoms and am seeking a medical diagnosis.
Name of healthcare provider offering diagnosis: ______________________________________________
4. I am caring for an individual subject to an order described in (reason 1) or self-quarantine as
described in (reason 2).
Revised 4/8/2020
__________________________________________________________________________________
Name of agency (for reason 1) or healthcare provider (for reason 2): _________________________________
Name and relationship of the individual I am caring for: ___________________________________________
5. I am caring for a child whose school/place of care is closed (or, my child care provider is otherwise
unavailable) for reasons related to COVID-19.
Name of care provider: _______________________________________________________________
Name(s) and age(s) of child(ren): _______________________________________________________
Please see below for additional required information related to this reason.
6. I am experiencing another substantially-similar condition specified by the Secretary of Health and
Human Services, in consultation with the Secretaries of Labor and Treasury. Please describe:
I am unable to telework or work an alternative schedule because the College cannot/does not offer
these options for my position.
I am unable to telework or work an alternative schedule due to a reason that is not listed. Please
describe: ___________________________________________________________________________
If
selecting reason 5
above:
I confirm that no other person will be providing care for the child(ren) during the period for which I am receiving family
medical leave. Enter initials here ___________
If the child(ren) is (are) between the ages of 14 - 17, I confirm that I have special circumstances that require the
child(ren) to be supervised by an adult (during business hours). Enter initials here ____________
If I have more than 30 days of work experience with the College, I understand that the submission of this form will be
considered an application for Emergency Paid Family Medical Leave. The approved time will be protected as described
in the FMLA Rights and Responsibilities poster, and I will be paid two-thirds of my pay after a two-week unpaid
period. The two-thirds pay is capped at $200 daily and $12,000 aggregate.
I wish to supplement my two-thirds emergency paid sick leave with additional paid leave (if available) so that I will
receive 100% of my regular pay.
I wish to supplement my two-thirds emergency paid family leave with additional paid leave (if available) so that I will
receive 100% of my regular pay.
I do not wish to supplement my two-thirds emergency paid leave.
I understand that some portions of this pay may be paid out of short-term disability (full-time employees only), my
annual or sick leave bank, or other sources, but in no cases will the two weeks emergency sick pay be deducted from
any leave bank that is not sick-specific.
Signature: ________________________________________________ Date: ___________________________
IMPORTANT:
Please attach evidence to support the reason for your request if it is related to leave for child care.
Examples of acceptable documentation are a school or childcare provider letter explaining that your child is enrolled and
unable to attend due to a closure, a copy of the quarantine or isolation order, or written documentation from a health
care provider.
Please contact Human Resources at humanresources@durhamtech.edu if you have any questions about this letter or
required documentation.
Revised 4/8/2020
click to sign
signature
click to edit
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome