Fillable KANSASSTATEUNIVERSITY updated /31/2020 FamiliesFirstCoronavirusResponseAct(FFCRA)LeaveRequestForm TheFamiliesFirstCoronavirusResponseAct(FFCRA)provideseligibleemployeeswithemergencypaidsickleave(EPSLA

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KANSASSTATEUNIVERSITY updated /31/2020 FamiliesFirstCoronavirusResponseAct(FFCRA)LeaveRequestForm TheFamiliesFirstCoronavirusResponseAct(FFCRA)provideseligibleemployeeswithemergencypaidsickleave(EPSLA)andinsomecasespaid emergencyfamilyandmedicalleave(EFMLEA)foremployeesunabletoworkduetoreasonsrelatedtoCOVID19.Additionalinformationand frequentlyaskedquestionsaboutleaveavailableunderFFCRAcanbefoundontheHCSwebsitehttps://www.kstate.edu/hcs/worklife/timeoff/leave.html. OnlycompletethisformtorequestleaveunderFFCRA.

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The KANSASSTATEUNIVERSITY updated /31/2020 FamiliesFirstCoronavirusResponseAct(FFCRA)LeaveRequestForm TheFamiliesFirstCoronavirusResponseAct(FFCRA)provideseligibleemployeeswithemergencypaidsickleave(EPSLA form is 1 page long and contains:

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KANSASSTATEUNIVERSITY
FamiliesFirstCoronavirusResponseAct(FFCRA)LeaveRequestForm
TheFamiliesFirstCoronavirusResponseAct(FFCRA)provideseligibleemployeeswithemergencypaidsickleave(EPSLA)andinsomecasespaid
emergencyfamilyandmedicalleave(EFMLEA)foremployeesunabletoworkduetoreasonsrelatedtoCOVID‐19.Additionalinformationand
frequentlyaskedquestionsaboutleaveavailableunderFFCRAcanbefoundontheHCSwebsitehttps://www.k‐state.edu/hcs/work‐life/time‐off/leave.html.
Instructions:
OnlycompletethisformtorequestleaveunderFFCRA. Leaverequestsforanyotherreasonshouldberequestedperyourdepartment’s
standardprocedures.ReturnthecompletedformtoyourdepartmentHCSLiaisonforprocessing.Contactyoursupervisorifyouneedhelp
contactingyourdepartmentHCSLiaison.
EmployeeandDepartmentInformation
EmployeeName: EmployeeID: HireDate SupervisorName:
EmployeeBestContactPhone: EmployeeK‐StateE‐mail: DepartmentName:
EmergencyPaidSickLeaveAct(EPSLA)RequestDetails(checkallthatapply)
□ QuarantinedbyaFederal,State,orlocalquarantineorisolationorderrelatedtoCOVID‐19
Orderissuedby:
□ Advisedbyahealthcareprovidertoself‐quarantinerelatedtoCOVID‐19
Advisedbyhealthcareprovidername:
□ ExperiencingCOVID‐19symptomsandseekingamedicaldiagnosis
Healthcareprovidername:
□ CaringforanindividualquarantinedbyaFederal,State,orlocalquarantineorisolationorderrelatedtoCOVID‐19
Orderissuedby:
□ Caringforanindividualwhohasbeenadvisedbyahealthcareprovidertoself‐quarantinerelatedtoCOVID‐19
Advisedbyhealthcareprovidername:
□ Caringformychildwhoseschoolorplaceofcareisclosed(orchildcareproviderisunavailable)forreasonsrelatedtoCOVID‐19
□ ExperiencinganyothersubstantiallysimilarconditionspecifiedbytheSecretaryofHealthandHumanServices
Effective5/31/20,applicableaccruedleavecanbeusedtosupplementEPSLA uptoyour regulardailyrateofpay. Pleaseindicatetheorderinwhich you wishtouse
youraccruedleavetosupplementapprovedEPSLleavebyplacinganumberintheboxes(1forleavetousefirst,etc.)orselecting“none”ifyoudonotwishtouse
accruedleave None(IdonotwishtosupplementEPSLAwithotheraccruedleave)
CompTime HolidayCompTime VacationLeave SickLeave(cannotbeusedforchildcarereasons)
EmergencyFamilyandMedicalLeaveExpansionAct(EFMLEA)RequestDetails(employeeswhohavebeenonpayroll30days)
□ Caringformychildwhoseschoolorplaceofcareisclosed(orchildcareproviderisunavailable)forreasonsrelatedtoCOVID‐19
ThefirsttwoworkweeksofEFMLEAmaybetakenasEPSL,accruedleave,orleavewithoutpay.EffectiveMay31,2020,fortheremaining10weeksofEFMLEA
applicableaccruedleavemustbeusedconcurrentlywiththeEFMLEAentitlementuntilaccruedleaveisexhausted.Afteraccruedleavesareexhausted,youwillbepaid
foranyremainingEFMLEAleaveentitlementsat2/3yourregulardailyrateofpaytoamaximumof$200perday.Pleaseindicatetheorderinwhichyouwishtouse
youraccruedleaveconcurrentlyandtosupplementapprovedEFMLEAleavebyplacinganumberintheboxes(1forleavetousefirst,etc.)
CompTime HolidayCompTime DiscretionaryDay VacationLeave
Ifleaverequestistocareforyourchild,pleasealsoprovidethe
f
ollowing
NameandageofChild(ren): Nameoftheschool,placeofcare,orchildcareproviderthathasclosedorbecomeunavailable:
Isthereanothersuitablepersonavailabletocareforthechild? ☐ YES ☐ NO
DatesofRequestedLeave
Listdatesofrequestedleave.Iftotalamountoftimeiscurrentlyunknown,listestimatedfirstdayofleave:
IcertifythatIamunabletoworkbecauseofthereasonsmarkedaboveandthattheinformationcontainedonthisformistrueandcorrecttothebestofmyknowledge.Forleave
taken to care foranother individual,Iconfirmthat theindividual is someone with whom I havearelationship, who is unable to care for themselves, and genuinelyneeds and
dependsonmycare.IauthorizeKansasStateUniversitytoobtainandverifyanynecessaryinformationregardingmyrequest.Iunderstandthat providingfalseinformationmay
resultincorrectiveactionupto,andincluding,separationofemployment.IunderstandthatIshouldstillfollowalldepartmentpolicies,includingcall‐outprocedures.
EmployeeSignature Date
updated
5
/31/2020
SelectoptionforfirsttwoworkweeksofapprovedEFMLEA
EPSLAAccruedLeave(intheorderindicated)LeaveWithoutPay
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KANSASSTATEUNIVERSITY updated 312020 FamiliesFirstCoronavirusResponseAct(FFCRA)LeaveRequestForm TheFamiliesFirstCoronavirusResponseAct(FFCRA)provideseligibleemployeeswithemergencypaidsickleave(EPSLA)andinsomecasespaid emergencyfamilyandmedicalleave(EFML

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Completed 21 August 2020

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