Fillable LEAVE REQUEST FORM FAMILIES FIRST CORONAVIRUS RESPONSE ACT

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LEAVE REQUEST FORM FAMILIES FIRST CORONAVIRUS RESPONSE ACT

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LEAVE REQUEST FORM
FAMILIES FIRST CORONAVIRUS RESPONSE ACT (FFCRA)
EMERGENCY PAID SICK LEAVE ACT (EPSLA) AND
EXPANDED FAMILY AND MEDICAL LEAVE EXPANSION ACT (EFMLA)
Name
Employee ID
Department/campus
Position
Email
Phone number
Date
Duration of leave (specify dates requested)
Leave benefits under the Families First Coronavirus Response Act (FFCRA) are available for the limited time
period of April 1, 2020 to December 31, 2020. The amount of paid leave an employee may receive will vary
depending on the reason leave is taken. Detailed information is available in the Employee Rights notice that can
be found on the Employee Benefit Website.
An employee requesting emergency paid sick leave (EPSLA) and expanded family and medical leave expansion
(EFMLEA) must complete this form and return it to EPISD Employee Benefits as soon as the need for leave is
identified. Documentation supporting the need for leave should be included when the request is submitted.
Emergency Paid Sick Leave (EPSL) is limited to 80 hours of paid leave at the following rates:
• Self: regular rate of pay up to $511 per day
• For care of an individual or a son or daughter: two-thirds the regular rate of pay up to $200 per day
Expanded Family and Medical Leave (EFML) provides up to 12 weeks of leave to care for a son or daughter when
school is closed or child care is unavailable due to COVID-19. The first two weeks are unpaid, although the
empoyee may access EPSL or other paid leave during this time. The remaining 10 weeks is two-thirds the regular
rate of pay up to $200 per day.
I request leave for the following reason(s):
Self
____ I’m subject to a federal, state, or local quarantine or isolation order related to COVID-19.
Name of entity requiring quarantine or isolation: ____________________________________________
____ I’ve been advised to self-quarantine by a health care provider.
Name of health care provider requiring quarantine or isolation: ________________________________
____ I’m experiencing symptoms of COVID-19 and am seeking a medical diagnosis.
Name of health care provider: __________________________________________________________
____ I’m expericing any other substantially-similar conditions specified by the U.S. Department of Health and
Human Services.
FFCRA Leave Request Form Page 2 of 2
June 10, 2020
Care for other individual or child
____ I’m unable to work in order to care for a minor son or daughter because their school is closed or child care
is not available due to COVID-19.
Name of school or child care facility: __________________________________________
Are you the only adult caring for the child(ren): _____yes _____no
Name and age of child(ren): ________________________________________________
If the son or daughter is over the age of 14 describe special circumstance requiring the care:
__________________________________________________________________________________
____ I’m unable to work in order to care for an individual subject or advised to quarantine or isolate.
Name of individual: ______________________________ Relationship: ________________________
Accrued leave use
Emergency Paid Sick Leave (EPSL):
___ I choose to use accured paid leave to “top off” the 2/3 pay covered by EPSL so I receive 100 percent
of my regular rate of pay.
Emergency Family Medical Leave Expansion (EFMLE):
___ I understand I’m required to use my accrued state and local leave concurrently with EFML. When
accrued leave is exhausted, I will receive 2/3 pay for any remaining EFML.
_________________________________________ _____________________________________
Employee Signature Date
_________________________________________ _____________________________________
Supervisor’s Acknowledgement Date
________________________________________________________________________________________
Designation (completed by Employee Benefits):
_____The employee qualifies for EPSL.
_____The employee does not qualify for EPSL.
_____The employee qualifies for _____ weeks of EFMLE.
_____The employee does not qualify for EFMLE.
For office use only:
Date of Employment ______________________________
Medical certification provided _____Yes _____ No
Approved
by:_____________________________________________
Name and title
Date:___________________________________________
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LEAVE REQUEST FORM FAMILIES FIRST CORONAVIRUS RESPONSE ACT

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Completed 20 May 2021

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