HUMAN RESOURCE SERVICES
85 South Prospect Street, Burlington, VT 05405
802.656.3150 · fax 802.656.3476
HRSInfo@uvm.edu · www.uvm.edu/hrs Equal Opportunity/Affirmative Action Employer
Families First Coronavirus Response Act (FFCRA) Leave Form
Instructions
Employees: Review FFRCA guidelines.
Complete and submit this form to your supervisor if you wish to request leave
under the FFCRA. Once approved, submit correct time reporting codes on your timesheet during your leave.
Supervisors: Complete and submit this form to your Dean's/Business Office. Review time in time reporting system(s)
(PeopleSoft or Kronos) and ensure correct time reporting codes based on the employee's leave.
Completed by Employee
Empl
ID
First
Name
Last
Name
Date
Prepared
Dept Term FTE
Temp
(Yes/No)
Emergency Paid Sick Leave (EPSL): Emergency Paid Sick Leave (EPSL): Allows up to 2 weeks of paid leave (up to 80 hours,
max $5,110). Except when used to substitute for the first 10 days of PHEL, EPSL must be used on consecutive days until
the reason for EPSL abates. EPSL does not need to be exhausted. Total hours of EPSL anticipated (will vary based upon
the number of hours per week scheduled): ______________
Start Date:
(no earlier than April 1, 2020)
End Date:
(no later than December 31, 2020)
Check the applicable qualifying reason:
Subject to Federal, State or local quarantine or isolation order related to COVID-19
Advised by healthcare provider to self-quarantine related to COVID-19
Experiencing COVID-19 symptoms and seeking medical diagnosis
Caring for an individual subject to quarantine due to COVID-19
Caring for your child whose school or place of care is closed due to COVID-19
Experiencing a substantially similar condition specified by the Dept. of Health and Human Services
EPSL may only be used intermittently to care for a child or dependent whose school or day care is closed.
I intend to use EPSL intermittently on Sun/Mon/Tues/Wed/Thurs/Fri/Sat (describe below) :
__________________________________________________ through (date) _____________________________
HUMAN RESOURCE SERVICES
85 South Prospect Street, Burlington, VT 05405
802.656.3150 · fax 802.656.3476
HRSInfo@uvm.edu · www.uvm.edu/hrs Equal Opportunity/Affirmative Action Employer
UVM Sick Time Deficit: If you exhaust all other paid leave options, UVM will allow you to borrow up to 10 days of sick
time (-80 hours max)against your future accruals if you are self-quarantining, exhibiting COVID-19 symptoms, or you are
unable to work or telework. If you go into a sick time deficit, you will not be able to use sick time until the deficit is paid
back. UVM reserves the right to recoup any remaining sick time deficit from the final paycheck of employees who
terminate before they regain a positive sick time balance.
I intend to use the sick time deficit.
Public Health Emergency Leave (PHEL): Must be employed at least 30 calendar days before you are eligible for this
leave. This leave allows up to 10 weeks of paid time, at 2/3 of regular base pay (up to $200 per day), to care for your
child whose school or place of care is closed due to COVID-19. PHEL may be used intermittently on a daily basis (e.g.
work Monday and Tuesday, use PHEL Wednesday through Friday). Note: Do not record hours on timesheet in less than
daily increments.
Start Date:
(no earlier than April 1, 2020)
End Date:
(no later than December 31, 2020)
I intend to use PHEL intermittently (describe days PHEL will be used):
_____________________________________________________________________________________________
Completed by Supervisor (check applicable)
Unable to telework a flexible schedule
Unable to telework due to nature of position
Employed for at least 30 days (for PHEL requests)
Approved Intermittent Schedule, if applicable
If temp, average number of hours worked per week
Completed by Dean’s/Business Office
For Temporary Employees ONLY:
See COVID Leave Process Document for details on how to determine the following fields.
Regular rate: ________________ per hour___ or per week___ (check one)
Average hours per week: ___________________
Employee will run out of all exception time and need to be placed into an unpaid leave status until they
are able to return to work.
HUMAN RESOURCE SERVICES
85 South Prospect Street, Burlington, VT 05405
802.656.3150 · fax 802.656.3476
HRSInfo@uvm.edu · www.uvm.edu/hrs Equal Opportunity/Affirmative Action Employer
Employee Signature: _______________________________________
Supervisor Approval: _______________________________________
Dean’s Office Approval: _____________________________________
Email completed form to Payroll Services: payroll@uvm.edu and cc: uvmler@uvm.edu.
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