Fillable Families First Coronavirus Response Act (FFCRA) Leave Form (University of Illinois)

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Families First Coronavirus Response Act (FFCRA) Leave Form (University of Illinois)

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Page 1 of 8
Revised 4/2020
University of Illinois
Families First Coronavirus Response Act (FFCRA) Leave Form
EMPLOYEE RIGHTS AND RESPONSIBILITIES
Under the Families First Coronavirus Response Act of 2020, employees may be eligible for emergency paid sick leave or
expanded family and medical leave from April 1, 2020 through December 31, 2020 if they are unable to work or telework
because of COVID-19 related reasons and meet the qualifying criteria.
Paid sick time provided under this Act does not carryover from one year to the next. Employees are not entitled to
reimbursement for unused leave upon termination, resignation, retirement, or other separation from employment.
The University of Illinois System’s FFCRA guidelines may be accessed here:
https://www.hr.uillinois.edu/leave/coronavirus_response_act
Emergency Paid Sick Leave
Eligibility
Employees are eligible from the first day of employment for Emergency Paid Sick Leave if they are unable to work or
telework for one of the six qualifying reasons.
Emergency Paid Sick Leave at regular rate of pay:
1. Employee is subject to a Federal, State, or local quarantine or isolation order;
2. Employee had been advised by a health care provider to self-quarantine;
3. Employee is experiencing symptoms of COVID-19 and seeking a medical diagnosis;
Emergency Paid Sick Leave at 2/3 of regular rate of pay:
4. Employee is caring for an individual who is subject to an order described in (1) or (2) above;
5. Employee is caring for a child of such employee if school or day care has been closed, or child care provider is
unavailable;
6. Employee is experiencing any other substantially similar condition specified by the Secretary of Health and
Human Services in consultation with the Secretary of the Treasury and the Secretary of Labor.
Amount of leave
• Full-time employees are eligible for up to two weeks of leave time, based on their regular schedule over a 2-week
period, up to a maximum of 80 hours.
• Part-time employees are eligible for a number of hours equal to the number of hours the employee works, on
average, over a 2-week period.
• Intermittent leave: Emergency Paid Sick Leave may only be taken intermittently if you are either a) teleworking,
or b) working at your usual worksite and requesting leave to care for your own child whose school or place of
care is closed, or whose child care provider is unavailable because of COVID-19 related reasons. If working at
your usual worksite, leave must be taken in full day increment unless requesting leave to care for your own child
whose school or place of care is closed, or whose child care provider is unavailable because of COVID-19 related
reasons.
Calculating leave pay
• Emergency Paid Sick Leave used for reasons 1-3 above will be paid at the employee’s regular rate of pay under
the FLSA.
Page 2 of 8
Revised 4/2020
• Emergency Paid Sick Leave used for reasons 4-6 above will be paid at 2/3 the amount of the employee's regular
pay.
Notice of leave request
• Employees are required to follow departmental/university sick leave notice procedures for their intent to use
Emergency Paid Sick Leave.
• Employees should complete the Employee Certification and the To Be Completed By Employee portion of the
FFCRA Leave Form and submit it to their applicable HR office (college/unit HR office, System HR for System
Office employees, or Hospital Leave Coordinator for UI Hospital and Clinics).
Expanded Family and Medical Leave
Eligibility
Employees are eligible for expanded family and medical leave after 30 days of employment if they are unable to work or
telework because their own child’s school or daycare has been closed, or the care provider is unavailable, due to COVID-
19.
Amount of leave
• Employees are eligible for 12 weeks of leave; the first 10 days are unpaid, with remaining 10 weeks paid at 2/3
regular rate of pay.
• Employees may substitute paid leave for the first 10 days at their option, including but not limited to Emergency Paid
Sick Leave.
• Expanded FML time is shared with FML under the University’s existing FML policy. Both types of FML together
may not exceed 12 weeks in a given leave year (the consecutive 12-month period beginning when the employee first
takes FML leave).
• Employees are not entitled to more than 12 total weeks of Expanded FML, even if the time spans two leave years.
• Expanded FML is not available when an employee has exhausted FML leave for the current leave year.
• Variable hour employees' leave will be calculated using the average number of hours worked per day over the prior 6
months. If the employee has not worked for 6 months, leave will be calculated using a reasonable expectation of the
average number of hours per day at the time of hiring.
• Intermittent leave: Expanded Family and Medical Leave may be taken intermittently.
Calculating leave pay
• The first 10 days of leave are unpaid, OR
• Employees may substitute accrued paid leave, including but not limited to Emergency Paid Sick Leave, for the first 10
days, at their option.
• The remaining 10 weeks will be paid at 2/3 the employee's regular rate of pay as defined by the FLSA and the number
of hours the employee would otherwise normally be scheduled to work.
Notice of leave request
• When leave is not foreseeable, requests should be made as soon as practicable and in advance of the leave if
possible. If the need for leave is foreseeable, requests should be made five (5) business days in advance of the
need for leave or within two (2) business days after learning of the need for leave. Employees should complete the
Employee Certification and the To Be Completed By Employee portion of the FFCRA Leave Form and submit
it to their applicable HR office (college/unit HR office, System HR for System Office employees, or Hospital
Leave Coordinator for UI Hospital and Clinics).
Page 3 of 8
Revised 4/2020
L
EAVE REQUEST FORM
TO BE COMPLETED BY EMPLOYEE
Employee Name: _____________________________________ UIN: ___________________________
Dept./Unit: __________________________________________
Office E-mail: __________________________________ Alternate E-mail: ________________________
Office Phone: __________________________________ Alternate Phone: ________________________
Title: _______________________________________________________________________________
Supervisor’s Name: ____________________________________________________________________
REASON FOR LEAVE
Emergency Paid Sick Leave (2 weeks, up to 80 hours):
Because of COVID-19, I am unable to work or telework because I (mark only one):
______ 1. Am subject to a Federal, State, or local quarantine or isolation order. (Paid at regular rate of
pay.)
______ 2. Have been advised by a health care provider to self-quarantine. (Paid at regular rate of pay.)
______ 3. Am experiencing symptoms of COVID-19 and seeking a medical diagnosis. (Paid at regular rate
of pay.)
______ 4. Am caring for an individual who is subject to an order described in (1) or (2) above. (Paid at
2/3 of regular rate of pay.)
______ 5. Am caring for my child under 18 years of age whose school or place of care is closed, or whose
child care provider is unavailable. (Paid at 2/3 of regular rate of pay.)
______ 6. Am experiencing any other substantially-similar condition specified by the U.S. Department of
Health and Human Services. (Paid at 2/3 of regular rate of pay.)
I ____ have or ________ have not received Emergency Paid Sick Leave previously (whether through the
University or a prior employer).
Expanded Family and Medical Leave (12 Weeks of Leave – 2 weeks unpaid, 10 weeks paid):
________Because of COVID-19, I am unable to work or telework because I am caring for my child under
18 years of age whose school or place of care is closed, or whose child care provider is unavailable. (Paid
at 2/3 of regular rate of pay.)
Page 4 of 8
Revised 4/2020
REQUEST TO USE BENEFITS
______ Emergency Paid Sick Leave (10 days), as paid according to qualifying reason for leave at either
regular rate of pay or 2/3 of regular rate of pay.
______ Expanded Family and Medical Leave (12 weeks), with 2 weeks unpaid and 10 weeks paid at 2/3
of regular rate of pay. I understand that the first two weeks of Expanded Family and Medical Leave is
unpaid unless I choose to use paid leave. I choose the following option during the unpaid period:
_______ 10 days unpaid leave OR
_______ 10 days paid Emergency Paid Sick Leave, as paid according to qualifying reason for
leave at either regular rate of pay or 2/3 of regular rate of pay. OR
________ 10 days accrued vacation leave
________ Floating Holidays
D
ATES FOR WHICH LEAVE IS REQUESTED
LEAVE WILL BE TAKEN AS
(check all that apply):
______ a block of time from _______________ to _______________
(month/day/year) (month/day/year)
____
__ intermittently (e.g., separate blocks of time or any part of a single day due to a single qualifying
reason)
(please describe on separate sheet and attach to application)
Start date of intermittent leave _____________________
NOTE: Emergency Paid sick leave may only be taken intermittently if you are either 1) teleworking, or 2) working at your usual
worksite and requesting leave to care for your own child whose school or place of care is closed, or whose child care provider is
unavailable because of COVID-19 related reasons. If working at your usual worksite, leave must be taken in full day increment
unless requesting leave to care for your own child whose school or place of care is closed, or whose child care provider is
unavailable because of COVID-19 related reasons. Expanded family and medical leave may be taken intermittently.
I
have read the “Employee Rights and Responsibilities” attached and understand all my rights and
obligations under this policy. I also understand that any leave taken as designated Expanded FMLA leave
(paid and/or unpaid) counts toward my FMLA leave entitlement.
____
_________________________________________ _____________
Employee Signature Date
Page 5 of 8
Revised 4/2020
EMPLOYEE CERTIFICATION FOR LEAVE REQUESTED UNDER THE FAMILIES FIRST
CORONAVIRUS RESPONSE ACT
Employee Name:
I request leave from _________________ to _________________ for the reason indicated below.
Expected Start Date Expected End Date
I am unable to work (including telework) because of the following reason:
_____ I am subject to a federal, state, or local quarantine or isolation order for Coronavirus.
Name of the governmental entity ordering quarantine or isolation:
_____ I am advised by a health care provider to self-quarantine due to Coronavirus concerns.
Name of the heath care provider advising to self-quarantine:
_____ I am experiencing symptoms of Coronavirus and seeking a medical diagnosis.
I understand that the symptoms are shortness of breath, fever, dry cough, and other symptoms identified
by the CDC. See https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html
I understand that leave is provided only for my affirmative steps to obtain a medical diagnosis, such as
making, waiting for, or attending an appointment for a test for COVID-19. I also understand that before
returning to work, I will need to provide a physician’s note or I will provide an attestation that I have
met CDC return-to-work requirements.
_____ I am caring for an individual who is under a quarantine or isolation order or has been advised by a health
care provider to self-quarantine due to Coronavirus concerns.
Please specify the individual, his/her relation to you, and his/her address:
Name of the governmental entity ordering quarantine or isolation:
Name of the heath care provider advising to self-quarantine:
Page 6 of 8
Revised 4/2020
_____ My minor child’s* school or child care facility has closed due to COVID-19.
or
_____ My minor child’s* child care provider is unable to provide services due to COVID-19.
For each child, please provide the following information (attach additional pages if necessary):
Name of Child Age Name of School or Child Care Facility/Provider
Name of Child Age Name of School or Child Care Facility/Provider
Name of Child Age Name of School or Child Care Facility/Provider
Name of Child Age Name of School or Child Care Facility/Provider
If leave is requested for a child over the age of 14 during daytime hours, the following special
circumstances exist, which require me to provide care:
Another suitable person will be caring for my child(ren) during the time for which I am requesting leave:
Yes No
* “Child” includes children under 18 years of age and children age 18 or older who are incapable of self-care
because of a mental or physical disability.
I certify and affirm that am unable to work (including telework) because of the above indicated reason
and that the information provided in this certification form is true and correct.
Date:
Employee Signature
Page 7 of 8
Revised 4/2020
TO BE COMPLETED BY
C
OLLEGE
/U
NIT
HR
OFFICE
,
S
YSTEM
HR
(
FOR
S
YSTEM
O
FFICE
EMPLOYEES), OR HOSPITAL LEAVE COORDINATOR (FOR UI HOSPITAL AND CLINICS)
1. Has employment commenced? Yes No
(If no, the employee is not eligible for Emergency Sick Leave.)
2. Has the employee been employed for at least 30 days? Yes No
(If no, the employee is not eligible for Expanded FMLA.)
3. If requesting Emergency Sick Leave, is the reason for the leave because of one of the 6 reasons for
qualifying leave? Yes No
4
. If
requesting Expanded FMLA leave, is the reason for the leave because employee is caring for their
child(ren), or standing in loco parentis of child(ren), under 18 years of age, or age 18 or older who are
incapable of self-care because of a mental or physical disability, whose school or place of care is closed,
or whose child care provider is unavailable?
Yes No
5. Does the employee’s documentation support the request for leave? Yes No
If no, please describe:
6
. The employee has _______ number of weeks/hours of FMLA leave entitlement remaining at th
e
ti
me of this leave request.
FMLA hours remaining after the employee takes Emergency FMLA leave will be shared with other
active FMLA events.
Based on the answers above, is the employee eligible for requested leave? Yes No
If no, state reason.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
The unit acknowledges that benefits will be applied as shown below:
_____ vacation leave hrs ______emergency sick hrs ____expanded FMLA hrs ____ unpaid hrs
_____ vacation leave days ______emergency full sick days ____expanded FMLA days ____ unpaid days
______ floating holidays ____emergency sick partial days
______ other: _______________________________________________________________________
Please sign below to indicate your review of this Emergency Sick Leave/Expanded FMLA request.
____
________________________________________ __________________________
Authorized Signature (Department, Unit, System HR, UI Hospital Leave Coordinator) Date
Page 8 of 8
Revised 4/2020
If the unit believes that the employee is not eligible for Emergency Sick Leave or Expanded FMLA, please consult
your central/campus Human Resources office before denying the leave. You may also contact HR if you have
additional questions.
The unit is responsible for tracking Expanded FMLA usage on an FMLA Usage Form available at
http://nessie.uihr.uillinois.edu/pdf/leave/FMLA-VESSA_Usage_rpt.xls
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Families First Coronavirus Response Act (FFCRA) Leave Form (University of Illinois)

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Completed 2 September 2020

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