Fillable Form 1.: APPLICATION FOR LEAVE EMERGENCY PAID SICK (Fontbonne College)

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Form 1.: APPLICATION FOR LEAVE EMERGENCY PAID SICK (Fontbonne College)

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1849175.2
APPLICATION FOR LEAVE
EMERGENCY PAID SICK LEAVE ACT
EMERGENCY FAMILY AND MEDICAL LEAVE EXPANSION ACT
1.
Name:
___________________________________________________________________________
2.
Emergency Paid Sick Leave Act
a. Are you applying for Emergency Paid Sick Leave?
Yes No
b.
Are you unable to work, including telework, for a reason related to COVID-19? Yes No
c. On what date(s) are you requesting Emergency Paid Sick Leave?________________________________
d. Identify the reason you are seeking Emergency Paid Sick Leave:
I am subject to a federal, state or local quarantine, isolation or shelter-in-place order related to
COVID-19.
Name of governmental entity ordering quarantine: _____________________________________
You must provide a copy of the governmental entity’s order.
I have been advised by a health care provider to self-quarantine due to concerns related to
COVID-19.
Name of the health care provider advising self-quarantine: _______________________________
You must provide a health care provider’s note stating that you are under medical advice to self-quarantine due
to concerns related to COVID-19.
I am experiencing symptoms of COVID-19 and seeking a medical diagnosis.
You must provide a health care provider’s statement or other medical documentation reflecting that you are
experiencing COVID-19 symptoms and seeking and/or have sought a diagnosis.
I am caring for an individual who is subject to a quarantine order as described above or who has
been advised by a health care provider to self-quarantine due to concerns related to COVID-19.
Name of person under quarantine order: ______________________________________________
Relation to you of the person under quarantine order: _________________________________
Name of governmental entity ordering quarantine: ______________________________________
You must provide a copy of the governmental entity’s order.
or
Name of the health care provider advising quarantine: ___________________________________
You must provide a health care provider’s note stating that the individual for whom you are caring is under medical
advice to self-quarantine due to concerns related to COVID-19.
Effective April 1, 2020, full-time employees may be entitled to up to 80 hours of paid sick leave for a
qualifying reason described in 2(d). Part-time employees are entitled to paid leave equal to the number of
hours the employee is normally scheduled to work over two workweeks. Paid sick leave shall not exceed:
• $511 per day and $5,110 maximum for employees who are under a governmental or medical
quarantine order or who are experiencing symptoms of COVID-19 and seeking medical diagnosis.
• $200 per day and $2,000 maximum for employees who are caring for quarantined or sick
individuals or for a child whose school or place of care is closed or unavailable due to COVID-19
related reasons. Leave for these purposes will be paid at 2/3 of the employee’s regular rate of pay
up to the maximum.
1849175.2
I am caring for my son or daughter whose school or place of care has been closed or childcare
provider is unavailable for reasons related to COVID-19.
i. For each child that you will care for, please provide the following information:
Name: ______________________________________________________________________
Age: _________________________________________________________________________
Name of school or place of care that is closed: ______________________________________
or
Name of unavailable childcare provider: ___________________________________________
You must provide a copy of a notice of closure or unavailability from your child’s school, place of care, or
childcare provider.
ii. Will another person be providing care for the child during the period of leave you are
requesting?
Yes No
iii. Is any other suitable person available to provide care for the child during the period of leave
you are requesting?
Yes No
iv.
For each child age 14 or older:
Are there special circumstances that exist that require you
to provide care for this child during daylight hours?
Yes No N/A
If “Yes,” please describe the special circumstances: _________________________________
_____________________________________________________________________________
v. Leave under this section may be taken to care for the eligible employee’s son or daughter
who is 18 years of age or older and (1) has a mental or physical disability and (2) is
incapable of self-care because of this disability. Do you believe you qualify for leave for this
reason?
Yes No N/A
vi. Emergency Paid Sick Leave is a continuous leave unless the employer and employee agree
to intermittent leave, and only when the reason for leave is childcare. Are you seeking
continuous or intermittent leave?
Continuous Intermittent
vii. If you are requesting intermittent leave, what schedule are you requesting and why is that
necessitated by your childcare needs?_____________________________________________
_____________________________________________________________________________
Please note that the employer will consider requests for intermittent leave but may or may not agree
to intermittent leave depending on the needs of the business. You will be advised whether
intermittent leave is available particular circumstances.
1849175.2
3.
Emergency Family and Medical Leave Expansion Act
a. Are you applying for leave under the
Emergency Family and Medical Leave Expansion Act
? Yes No
b. Are you unable to work, including telework, because you are caring for your child whose school or place of
care is closed or childcare provider is unavailable for reasons related to COVID-19. Yes No
c. On what date(s) are you requesting Emergency Family and Medical Leave? ________________________
d. For each child that you will care for, please provide the following information:
Name: _____________________________________________________________________________
Age: _______________________________________________________________________________
Name of school or place of care that is closed: ____________________________________________
or
Name of unavailable childcare provider: __________________________________________________
You must provide a copy of a notice of closure or unavailability from your child’s school, place of care, or childcare provider.
e. Will another person be providing care for the child during the period of leave you are requesting?
Yes No
f. Is any other suitable person available to provide care for the child during the period of leave you are
requesting?
Yes No
g.
For each child who is older than age 14:
Are there special circumstances that exist that require you to
provide care for this child during daylight hours?
Yes No N/A
If “Yes,” please describe the special circumstances: _________________________________________
____________________________________________________________________________________
h. Leave under this section may be taken to care for the eligible employee’s son or daughter who is 18 years of
age or older and (1) has a mental or physical disability and (2) is incapable of self-care because of this
disability. Do you believe you qualify for leave for this reason?
Yes No N/A
i. Emergency Family and Medical Leave Expansion is a continuous leave unless the employer and employee
agree to intermittent leave. Are you seeking continuous or intermittent leave? Continuous Intermittent
j. If you are requesting intermittent leave, what schedule are you requesting and why is that necessitated by
your childcare needs?
________________________________________________________________________________________
________________________________________________________________________________________
Please note that the employer will consider requests for intermittent leave but may or may not agree to intermittent
leave depending on the needs of the business. You will be advised whether intermittent leave is available particular
circumstances.
This Act provides for up to 12 weeks of leave between April 1, 2020 and December 31, 2020 for an eligible
employee who has been employed for at least 30 days and has a need to take leave due a qualifying need due
to COVID-19 related reasons. The first two weeks of leave are unpaid, but the employee may choose to
substitute Employee Paid Sick Leave (see Section 2, above) or may substitute other available paid time off. This
expanded FMLA leave is paid at 2/3 of the employee’s regular rate of pay and shall not exceed $200 per day
and $10,000 maximum. Leave available under the Emergency Family and Medical Leave Expansion Act will run
concurrently with leave under the Paid Sick Leave Act when the employee applies and qualifies for both.
1849175.2
Verification
In submitting this Application for Leave, I certify
that the information I have provided is complete, correct, and true. I
agree to provide all documentation required by my employer to verify the need for leave, whether it is specifically
noted on this Application for Leave form or whether I am informed of the need for additional or other documentation
after I submit this Application for Leave. I acknowledge and understand that my request for leave may be denied if I
fail to provide all required documentation and that other employment action may be taken against me if any of the
information I provided on this application is incomplete, incorrect or untruthful. I have agreed to use electronic
means to sign this Application for Leave, and my electronic signature has the same force and effect as my manual
signature.
Employee Signature Date
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Form 1.: APPLICATION FOR LEAVE EMERGENCY PAID SICK (Fontbonne College)

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Completed 29 January 2021

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