Fillable Families First Coronavirus Response Act Request Form (State of Rhode Island)

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Families First Coronavirus Response Act Request Form (State of Rhode Island)

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The Families First Coronavirus Response Act Request Form (State of Rhode Island) form is 2 pages long and contains:

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  • 2 check-boxes
  • 19 other fields

Country of origin: US
File type: PDF

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Families First Coronavirus Response Act Request Form Page 1 of 2
Please type or print clearly.
Employee Name:
Title:
Department:
Division:
Date of Hire:
Leave Dates Requested
Are you requesting an intermittent leave? _____ Yes _____ No
If yes, please explain:
If approved for telework, please provide the reason you are unable to telework due to a need for leave because of
COVID-19 related reasons:
Families First Coronavirus Response Act
Request Form
The Families First Coronavirus Response Act (the “FFCRA”), effective April 1, 2020, provides State employees with
additional emergency paid sick leave and expanded family and medical leave for specified reasons related to
COVID-19. These provisions apply to leave taken between April 1, 2020 and December 31, 2020.
Emergency Paid Sick Leave: Full time eligible employees in a 40 hour work week may discharge up to eighty (80)
hours of emergency paid sick leave, at the employee’s regular rate of pay (part-time employees may discharge sick
leave in an amount equal to the number of hours that he or she works, on average, over a two (2) week period –
this includes employees who are scheduled to work 35 hour per week as they are considered to be part-time
under the FFCRA) if the employee is unable to work, or telework, due to a reason listed below.
Emergency Family and Medical Leave Act Expansion: Employees who have been employed for at least thirty (30)
days prior to their leave request, may be eligible for up to two (2) weeks of unpaid and ten (10) weeks of partially
paid expanded family and medical leave where an employee is unable to work or telework under the State’s
Teleworking Policy due to a bona fide need for leave to care for the employee’s child if the child’s school or place
of care has been closed, or the child care provider of such child is unavailable, due to a public health emergency
declared by a Federal, State or local authority as a result of COVID-19.
Employee Name: _______________________
Families First Coronavirus Response Act Request Form Page 2 of 2
Qualifying COVID-19 reasons for leave.
Please check the reason you are requesting leave and provide the required documentation:
1) I am subject to a Federal, State or local quarantine or isolation order related to COVID-19
Required Documentation: Copy of the Quarantine or Isolation Order
2) I have been advised by a health care provider to self-quarantine due to concerns related to COVID-19
Required Documentation: Written documentation from the health care provider who advised you to
self-quarantine for COVID-19 related reasons
3) I am experiencing symptoms of COVID-19 and am seeking a medical diagnosis
Required Documentation: Written documentation from the health care provider that you are
experiencing symptoms of COVID-19 and are seeking a medical diagnosis
4) I am caring for an individual who (a) is subject to a Federal, State or local quarantine or isolation order or
(b) has been advised by a health care provider to self-quarantine due to concerns related to COVID-19
Required Documentation: (a) a copy of the quarantine or isolation order; or (b) written documentation
from the health care provider who advised the individual being cared for to self-quarantine due to
COVID-19 reasons
Name of individual being cared for: __________________________________________
Relationship to individual being cared for: _____________________________________
5) I am caring for my son or daughter because the school or place of care has been closed or the childcare provider
is unavailable, due to COVID-19 precautions
Required Documentation:
a) Notice of closure or unavailability from child(ren)’s school, place of care, or child care provider,
including a notice that may have been posted on a government, school or day care website, published in
a newspaper, or emailed to you from an employee or official of the school, place of care, or child care
provider
b) Name(s) of child(ren) being cared for:
_____________________________________________________________________________________
c) Statement representing that no other suitable person is available to care for the child(ren) during the
period of requested leave
6) I elect to use accrued paid leave to supplement pay under emergency paid sick leave, pursuant to reason 4 or 5,
so that I receive the full amount of my bi-weekly wages
Type of leave to be used: ______________________
Signature of employee requesting leave: ________________________________________________________________
Telephone Number: _________________________________ Email Address: __________________________________
Supervisor’s Printed Name: ___________________________________ Date: __________________________________
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Families First Coronavirus Response Act Request Form (State of Rhode Island)

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Completed 20 May 2021

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