LEAVE REQUEST FORM
FAMILIES FIRST CORONAVIRUS RESPONSE ACT (FFCRA)
EMERGENCY PAID SICK LEAVE ACT (EPSLA) AND
EXPANDED FAMILY AND MEDICAL LEAVE EXPANSION ACT (EFMLA)
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):
____ 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