LSU Request for Emergency Paid Sick Leave
To request emergency paid sick leave as provided under the Families First Coronavirus Response Act,
please complete the following request form and submit to Alexa Butcher at email@example.com as soon
as possible before leave commences.
Under the FFCRA, you are unable to work if your employer has work for you to do, but one of the
qualifying needs below prevents you from being able to perform that work, either at your regular
worksite or by means of remote work.
Documentation supporting the need for leave must be included with this request.
e Name (print clearly): ________________________________________________
Department: __________ ______________
Manager: ____________________ _______
Requested Leave Start Date: ________________ End Date: __________________
The amount of emergency paid sick leave being requested is __________ hours (maximum 80 hours).
I am requesting this emergency paid sick leave due to my inability to work (or telework) because (check
the appropriate reason below):
❏ 1) I am subj
ect to a federal, state, or local quarantine or isolation order related to COVID–19.
❏ 2) I have been advised by a health care provider to self-quarantine due to concerns related to
❏ 3) I am experiencing symptoms of COVID–19 and seeking a medical diagnosis.
4) I am caring f
or an individual who is subject to either number 1 or 2 above. (The individual
must be an immediate family member or someone who regularly resides in your home.)
5) I am caring f
or my child whose primary or secondary school or place of care has been
closed, or my child care provider is unavailable due to COVID–19 precautions; and,
❏ I attest that no other suitable person is available to care for my child during the
requested period of leave.
❏ I attest special circumstances exist requiring my need for leave to care for a child
❏ 6) I am experiencing another substantially similar condition specified by the secretary
of health and human services.
Optional: ❏ I wish to take intermittent leave for reason #5 above.
Please provide your email and/or telephone number below and we will contact you.
Telephone: ____________________ Email: _______________________
I have attached appropriate documentation supporting my need for leave.
Employee Signature: Date:
Manager Signature: Date:
HR Department Rep. Signature: Date:
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