Families First Coronavirus Response Act (FFCRA)
Request Form
Employee Name: Employee ID: _______________________
Supervisor: _______________________ Department: _________________________________________________
Phone #: _________________________ MSU E-Mail: __________________________________________________
Type: Continuous Intermittent Both
Leave Start date: End date:
Emergency Paid Sick Leave
Requesting Emergency Paid Sick Leave due to reason (check one):
1. Subject to a government quarantine or isolation due to COVID-19 (if not instructed by state or federal quarantine,
documentation is required);
2. Advised by a healthcare provider to self-quarantine due to COVID-19 (documentation required);
3. Experiencing the symptoms of COVID-19 and are seeking a diagnosis (documentation required);
4. Caring for an individual subject to or advised to quarantine or isolate (documentation required);
5. Caring for a son or daughter whose school or childcare is closed or unavailable due to COVID-19 (documentation
required for day care closing) this reason qualifies for up to an additional 10-week period of paid leave beyond the
first 80 hours granted under Emergency Paid Sick Leave; or
6. Experiencing substantially similar conditions as those specified by the Secretary of Health and Human Service in
consultation with the Secretaries of Labor and Treasury.
*All documentation should be emailed to HR@minotstateu.edu or faxed to 701-858-3686
I have read page 2 and understand I may be required to submit supporting documentation as soon as possible, but no
later than 15 days.
I understand that leave used will be counted towards my annual 12-week FMLA eligibility
I select to supplement my pay with eligible sick or annual leave per policy.
__________________________________________________
Employee Signature Date
_______________________________________
Signature Date
_______________________________________
Signature Date
_______________________________________
Signature Date
VPFA
Division VP
Human Resources
Eligible
Not Eligible
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Emergency Paid Sick Leave (EPSL)
Eligible:
Employees, upon first day of hire
Provides:
Up to 80 hours of compensation (pro-rated for part-time workers)
Compensation:
Reasons 1-3 below: Regular rate of pay up to $511 per day, and $5,110 in aggregate.
Reasons 4-6 below: two-thirds of the regular rate of pay up to $200 per day, and $2,000 total in aggregate.
This leave is separate from accrued annual leave and sick leave.
Eligible reasons to use EPSL:
To care for self:
1. Subject to a government quarantine or isolation order due to COVID-19 (if not instructed by state or federal quarantine
need to provide documentation);
2. Advised by a healthcare provider to self-quarantine due to COVID-19 (documentation required);
3. Experiencing the symptoms of COVID-19 and are seeking a diagnosis (documentation required);
To care for others:
4. Caring for an individual subject to or advised to quarantine or isolate (documentation required);
5. Caring for a son or daughter whose school or childcare is closed or unavailable due to COVID-19 (required for day care
closing); or
6. Experiencing substantially similar conditions as those specified by the Secretary of Health and Human Services in
consultation with the Secretaries of Labor and Treasury.
Required documentation:
For EPSL, the employee is required to provide “appropriate documentation” identifying the reason for requesting leave, a
statement that the employee is unable to work (including telework) for that reason, and the date(s) for which leave is
requested. This documentation may include:
The source of any quarantine or isolation order and may include a copy of the Federal, State or local quarantine or
isolation order related to COVID-19 applicable to the employee.
The name of the health care provider who has advised the employee to self-quarantine, including, for example,
written documentation by a health care provider advising the employee to self-quarantine due to concerns related
to COVID-19.
Emergency Family and Medical Leave
Eligible:
Employees employed 30 days or more
Employees unable to work (or telework) due to caring for a child whose school or childcare is closed or
unavailable due to COVID-19
Provides:
Up to 12 weeks of job protected leave
This leave is subject to the FMLA 12-week annual maximum
Compensation:
First 10 days of the leave are unpaid, may substitute EPSL, annual leave, or sick leave.
Ten remaining weeks of leave are paid at two-thirds of the regular rate of pay, not to exceed $200 per day and
$10,000 in aggregate.
This leave is separate from accrued annual leave and sick leave.
Required documentation:
If an employee takes EPSL and/or FMLA+ to care for his or her child whose school or place of care is closed due to COVID-
19, employees again must provide “appropriate documentation” in support of leave. Examples include:
A notice that has been posted on a government, school, or day care website, or published in a newspaper; or
An email from an employee or official of the school, place of care, or child care provider
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