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Houston ISD Absence Management

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Houston ISD Absence Management
Leave of Absence Application – COVID-19
Section A – TO BE COMPLETED BY EMPLOYEE
Employee Name
Employee ID:
Position Contact Number
Work
Date:
Employee’s Signature:
COVID-19 FMLA Request DESIGNATION
( ) Self ( ) Shelter-in-place ( ) Illness
( ) Child ( ) Child Care ( ) Illness: DOB:
Child’s name:
( ) Family Member ( ) Shelter-in-place ( ) Illness
FAMILY MEMBER NAME/RELATIONSHIP
FAMILY MEMBER NAME/RELATIONSHIP
Employee’s Home Address City State Zip
Leave Request: (e.g. 01/31/2020)
From / / to / /
Last Day Worked:
/ /
Intermittent Leave
( ) No ( ) Yes
COVID 19 REASON
In general, employees are eligible for up to two weeks of fully or partially paid sick leave for COVID-19 related reasons (see below). Employees who
have been employed for at least 30 days prior to their leave request may be eligible for up to an additional 10 weeks of partially paid expanded family
and
medical leave for reason #5 below.
An employee is entitled to take leave related to COVID-19 if the employee is unable to work, including unable to telework, because the employee:
1. is subject to a Federal, State, or local quarantine or isolation order related to COVID-19;
2. has been advised by a health care provider to self-quarantine related to COVID-19;
3. is experiencing COVID-19 symptoms and is seeking a medical diagnosis;
4. is caring for an individual subject to an order described in (1) or self-quarantine as described in (2);
5. is caring for his or her child whose school or place of care is closed (or childcare provider is
unavailable) due to COVID-19 related reasons; or
Please attach supporting
documentation
6. is experiencing any other substantially similar condition specified by the U.S. Department of Health and
Human Services.
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Houston ISD Absence Management

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Completed 27 January 2021

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