Request for Emergency Paid Sick Leave/Emergency FML Expansion
Families First Coronavirus Response Act (FFCRA)
Request for FFCRA Leave Form April 2020
Employee Name:
Employee ID:
Job Title:
Division/Department:
Classification:
Full-Time: Part-Time:
Exempt: Non-Exempt:
Supervisor Name:
Supervisor email/Ext.:
PERMISSIBLE USE OF LEAVE
Select at
least one (1)
Qualifying Reasons to Use Emergency Paid Sick Leave or Emergency FML Expansion under FFCRA if I
am unable to work (or telework)
1.
I am subject to a federal, state, or local quarantine or isolation order related to COVID-19 that specifically
prevents me from working. Name of the government entity issuing the order: _______________________
2.
I have been advised by a health care provider to self-quarantine because of concerns related to COVID-19.
Name of the advising healthcare provider: _____________________________________________________
3.
I have symptoms of COVID-19 and I am seeking (or have sought) a diagnosis.
4. I am caring for another individual who is subject to quarantine or has been advised by a health care
provider to self-quarantine related to COVID-19.
Name of person I am caring for: ____________________Relationship: ________________________
Name of the government entity issuing the order: ______
_________________________________________
OR
Name of the advising healthcare provider: _____________________________________________________
5. I need to care for my child(ren) because their school or childcare provider is closed or unavailable because
of COVID-19. I certify that no other suitable person is available to care for the child(ren) during the period
of requested leave.
Name(s) and age(s) of child(ren):
Name of closed school(s) or place(s) of care:
I have been employed for at least 30 days.
Request f
or Dates of Emergency Paid Sick Leave or Emergency FML Expansion under FFCRA
Month
Dates Requested (Additional detail may be attached to this
form. Exempt employees must use time in full day
increments if not covered under FML.)
of Hours
Requested
Total Number of
Hours Used Prior
to this Request
under FFCRA
Total
Number of
Hours
Remaining
in Allotment
Total Hours
I
I I I
I I I
I I I
I I I
Clear Form
Request for Emergency Paid Sick Leave/Emergency FML Expansion
Families First Coronavirus Response Act (FFCRA)
Request for FFCRA Leave Form April 2020
To the best of my knowledge and belief, I certify that the facts stated are accurate. I understand I may be asked to
substantiate the reason for the leave in accordance with the federal or state law, current Collective Bargaining Agreements
and/or CSU Policies. Where Federal law is in conflict with current Collective Bargaining Agreements and/or CSU Polices,
Federal law prevails. I understand that dishonesty is grounds for discipline.
Employee Name: _______________________________ Signature: ____________________________ Date:____________
I acknowledge the employee’s request for FFCRA paid leave as indicated above.
Appropriate Administrator Name: ___________________________ Signature: ________________________Date: ________
NOTE: HUMAN RESOURCES SHOULD BE CONSULTED PRIOR TO ANY APPROVAL/DENIAL BEING COMMUNICATED TO THE
EMPLOYEE.
HR/Academ
ic Personnel Office Approval of Qualifying Reason for Time Requested, Type of Paid Leave Requested and
Length of Time Requested
Employee is eligible for up to 80 hours of paid sick leave (prorated for part-time employees). Leave time is
paid at the employee’s regular rate of pay.
Employee is eligible for up to 12 weeks of expanded FMLA leave, under reason 5. The first 10 days may be
unpaid or employee may use accrued paid leave or FFCRA emergency sick leave. Remaining leave time after
the first 10 days is at the employee’s regular rate of pay.
HR/Academic Personnel Designee Name: _____________________ Signature:____________________ Date:_______
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