Created 04.09.20 1
Procedure: The Families First Coronavirus Response Act
(FFCRA or Act) requires certain employers, including Tarleton State University, to
provide employees with 10 days of emergency paid sick leave (hours prorated for part-time employees) (EPSL) and expanded family and
medical leave (EFMLA) for specified reasons related to COVID-19 if an employee is unable to work, to include telework. These provisions
will apply from April 1, 2020 through December 31, 2020 to all employees. Submit the completed and signed form to Employee Services
via email to
benefits@tarleton.edu.
To Be Completed by EmployeePlease print or type.
Employee Name: _____________________________________
UIN: ________________________________________________
Title: _______________________________________________
Department: _________________________________________
Primary Work Location: _______________________________
Supervisor: __________________________________________
Proposed Start Date: _________________________________
Proposed End Date: __________________________________
Do you have an active Alternate Work Location agreement? Yes No
SECTION A
Select the reason you are unable to work, to include telework, by checking the appropriate item below. Supporting documentation is
required for each item. (See guidance at bottom of page 2.) If written documentation is not readily available, forward it to Employee
Services as soon as available. Do not share medical background information.
1. I am subject to a Federal, State, or Local quarantine or isolation order related to COVID-19.*
Name of the issuing government agency for the quarantine or isolation order:
______________________________________________________________________________________________________
Effective dates of the order: _______________________________________________________________________________
2. I have been advised by a health care provider to self-quarantine related to COVID-19.*
Name of the health care provider advising me to self-quarantine:
______________________________________________________________________________________________________
Effective dates of the order: _______________________________________________________________________________
3. I am experiencing COVID-19 symptoms and am seeking a medical diagnosis.* Select one:
___ I am experiencing symptoms of COVID19 and have an appointment scheduled on ________________________________
___ I am experiencing symptoms of COVID19 and am waiting on results to disclose the medical diagnosis.
Name of the entity I am seeking medical treatment from: _________________________________________________________
Date of appointment/treatment: _____________________________________________________________________________
4. I am caring for an individual subject to an order described in (1) or self-quarantine as described in (2).*
Name of the health care provider advising the individual I am caring for:
______________________________________________________________________________________________________
Name and relation of the individual who I am needed to care for: _
Effective dates of the order or date of appointment: _____________________________________________________________
5. I am experiencing a substantially-similar condition as specified by the Secretary of Health and Human Services, in
consultation with the Secretaries of Labor and Treasury.*
Provide details regarding the need for this leave:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
6. I am caring for a child whose school or place of care is closed (or child care provider is unavailable) for reasons related to
COVID-19. **
Name of school or place of care: ____________________________________________________________________________
OR
Name of unavailable child caregiver:___________________________________________
Name and age of child or children I am needed to care for:
Name: ________________________________ Age: _____________________________
Name: ________________________________ Age: _____________________________
Name: _________________________________ Age: _____________________________
No other suitable person is available to care for my child for the requested leave period due to:
_______________________________________________________________________________________________________
The special circumstances requiring my need for leave to care for a child ages 15-17 are:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Tarleton State University
Families First Coronavirus Response Act (FFCRA) Request Form
Emergency Paid Sick Leave (EPSL)
Emergency Family and Medical Leave (EFMLA)
2
Tarleton State University
Families First Coronavirus Response Act (FFCRA) – Page 2
Emergency Paid Sick Leave (EPSL)
Emergency Family and Medical Leave (EFMLA)
Time off work is expected to be (select the most appropriate box):
For a continuous block of time.
For a reduced work schedule (change in work schedule neededfewer hours per day or fewer hours per week).
If a reduced work schedule is needed, indicate the days and hours you request to be on intermittent leave:
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
If you selected (6) from page 1 that you are caring for a child whose school or place of care is closed (or child care provider is
unavailable), complete Sections B and C. If you selected 1-5, skip Section B and complete Section C.
SECTION B
An employee is entitled to Emergency Family and Medical Leave (EFMLA) which is a separate FFCRA benefit from the EPSL, if the
employee has been employed for at least 30 days, has not already utilized 12 weeks of FMLA Leave since September 1, 2019, and leave
is needed to care for a minor child due to school or child care unavailability due to a public health emergency. EFMLA provides up to
12-weeks of job protected leave to care for a child whose school or place of care is closed due to COVID-19, to be paid after the first 2
weeks.
The first 10 days of EFMLA Leave are unpaid unless you ELECT to utilize available paid leave. Please indicate below if you wish to
elect paid or unpaid leave for the first 10 days of EFMLA.
Select one:
I wish to be unpaid for the first two weeks (10 days) of EFMLA.
I wish to use Emergency Paid Sick Leave (EPSL) for the first two weeks of Emergency FMLA leave (EFMLA), if not previously used.
I have already used all or some of my Emergency Paid Sick Leave (EPSL) and wish to use the following accrued leave balances
available to cover the remainder of the first two weeks of Emergency FMLA leave (EFMLA) (Check all that apply).
Sick Leave
FLSA Comp Time
State Comp Time
Vacation Leave
Birthday Leave
SECTION C
Employee Acknowledgement: I attest that the above information is accurate and complete. I understand falsification of any information given
may lead to disciplinary action, up to and including termination of employment. By signing, I affirm I have communicated with my supervisor that I
am unable to work, to include telework, for the reason identified on this request. In addition, I understand that I am responsible for forwarding the
necessary medical and/or daycare documentation as quickly as possible, if not available upon submission.
* Provide written documentation from health official or health care provider confirming effective dates advising employee to self-
quarantine or self-isolate and/or date of treatment for COVID-19 related reasons.
**Provide a notice published by the government, school or daycare of the closure. Examples include a notification on the provider’s
website, newspaper notification or email from the school or place of care.
Employee Signature: _____________________________
Date: ________________________
Supervisor Acknowledgement: By signing, I confirm I have communicated with the employee and assessed the feasibility of an
Alternate Work Location Agreement or Alternate Work Schedule. I confirm the employee is unable to work, to include telework, for the
reason selected on page 1.
Date: _______________________ Approve Do Not Approve
Date: ________________________ Approve Do Not Approve
Date: ________________________ Approve Do Not Approve
Vice President: _____________________________________
Date: ________________________ Approve Do Not Approve
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