Fillable Form 1: Request for Benefits under the Families (Chesterfield County, VA)

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Form 1: Request for Benefits under the Families (Chesterfield County, VA)

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U.S.A. forms for Chesterfield County, VA

BROWSE CHESTERFIELD COUNTY, VA (VA) FORMS

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Employee Name:
Employee ID:
Department:
Full-time or Part-time:
Emergency Paid Sick Leave:
I am unable to work or telework and am requesting Emergency Paid Sick Leave (“EPSL”) beginning under the
Families First Coronavirus Response Act for reason indicated below.
I am subject to a Federal, State or local quarantine or isolation order related to COVID-19. The quarantine order is
related to the following condition
1
:
Age 65 or older
Underlying medical condition
I have been advised by a health care provider to self-quarantine related to COVID-19
1
.
I am experiencing COVID-19 symptoms and am seeking a medical diagnosis
1
.
I am caring for an individual who is subject to a Federal, State or local quarantine or isolation order, or who has
been advised by a health care provider to self-quarantine related to COVID-19
2
.
I am caring for a child whose school or place of care is closed for reasons related to COVID-19
2
. *If you require leave
longer than two weeks/80 hours for this reason, and suitable childcare is not available, please continue to the Emergency
Family and Medical Leave Expansion Act (“EFMLEA”) section below.
I am experiencing any other substantially-similar condition specified by the Secretary of Health and Human
Services, in consultation with the Secretaries of Labor and Treasury
2
.
Please explain:
1
Emergency Paid Sick Leave under this provision is paid at the employee’s regular rate of pay, up to a maximum of $511/day and $5,110 in total
2
Emergency Paid Sick Leave under this provision is paid at 2/3 of the employee’s regular rate of pay, up to a maximum of $200/day and $2,000 in total
EFMLEA (Departments must submit a Place on FMLA webform):
I am unable to work or telework because I am caring for my son or daughter whose school or place of care is closed, or
whose childcare provider is unavailable, for reasons related to COVID-19 and am requesting EFML beginning
under the Families First Coronavirus Response Act.
Name of Child
Date of Birth
School/Childcare Provider
By signing below, I am attesting that the information above is true and accurate. Falsification on this document could
lead to disciplinary action, up to and including termination and repayment of any payments received to which I was not
eligible.
I would like to use EPSL to cover the first two weeks of unpaid EFMLEA.
YES NO
I would like to use my accrued leave to supplement my pay if I am receiving 2/3 of my regular rate of pay.
YES NO
Employee Signature*
Date
My signature below indicates that telework is not available to the employee.
Department Director Signature*
Date
*Typed names in the signature box will be accepted. An email copy of this form is acceptable from the employee to the
department director, and from the department director to Human Resources (email to brittlek@chesterfield.gov
).
Request for Benefits under the
Families First Coronavirus Response Act (FFCRA)
Request for Benefits Under the Families First Coronavirus Response Act
Listed below is the documentation required to support the request for benefits.
If the employee:
1) requests leave because of a Federal, State, or local quarantine or isolation order related to COVID-
19, a signed statement indicating what quarantine order applies;
2) has been advised by a health care provider to self-quarantine related to COVID-19, a notice from
the health care provider;
3) is experiencing COVID-19 symptoms and is seeking a medical diagnosis, a notice from the health
care provider;
4) is caring for an individual subject to an order described in (1) or self-quarantine as described in
(2); the same documentation as listed in (1) or (2) above;
5) is caring for a child whose school or place of care is closed (or childcare provider is unavailable)
for reasons related to COVID-19, completion of the EFMLEA section of the form. In addition to the
information listed above, the employee must also provide a notice of closure or unavailability from
the employee’s child’s school, place of care, or childcare provider, such as a notice that may have
been posted on a government, school, or day care website, published in a newspaper, or emailed
to the employee from an employee or official of the school, place of care, or childcare provider.
The County must retain this notice or documentation in support of the EFMLEA for four years; or
6) is experiencing any other substantially-similar condition specified by the Secretary of Health and
Human Services, in consultation with the Secretaries of Labor and Treasury, a notice from the
health care provider or other documentation as determined based on condition.
HR Use Only
Hire Date: Employee Type:
# of EPSL Hours: Pay Amount:
HR Status: Pay Class:
EPSL Begin Date: EPSL End Date:
EFMLEA Begin Date: EFMLEA End Date:
HR has confirmed the employee has not already used EPSL.
Approved
Denied Reason for denial:
HR Representative:
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Form 1: Request for Benefits under the Families (Chesterfield County, VA)

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Completed 2 August 2020

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