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 abutcher1@lsu.edu 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.
Employe
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 COVID19.
2) I have been advised by a health care provider to self-quarantine due to concerns related to
COVID19.
3) I am experiencing symptoms of COVID19 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 COVID19 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
ages 15-17.
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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Employee Statement Supporting Leave
I,
, provide the following information in support of my request for
emergency paid sick leave (complete all that apply):
Leave due to a government-issued quarantine or isolation order (Reason #1 and/or #4)
Name of the issuing government agency for the quarantine or isolation order:
Effective dates of the order:
Leav
e due to a health care provider’s advice to self-quarantine (Reason #2 and/or #4)
Name
of the health care provider advising me or the individual I am caring for to
self-quarantine:
Written documentation is available and attached: Yes No
Name
and relation of the individual who I am needed to care for:
Name: Relation:
Leav
e due to experiencing symptoms of COVID19 and seeking a medical diagnosis (Reason #3)
Date o
f scheduled appointment with a health care provider: _________________
Name of health care provider: __________________________________________
Date of scheduled COVID-19 test: _______________________________________
*Once the appointment or test occurs, documentation must be provided.*
Leav
e due to a school or place of child care closed due to COVID-19 (Reason #5)
Name of school or place of care:
Name of child caregiver unavailable due to concerns related to COVID-19:
Name, age, and relationship to me of child or children I am needed to care for:
Name: Age: Relation: ___________________
Name: Age: Relation: ___________________
Name: Age: Relation: ___________________
No other suitable person is available to care for my child for the requested leave period due to:
The special circumstances requiring my need for leave to care for a child ages 15-17 are:
Leav
e due to a substantially similar condition specified by the secretary of health and human services
(Reason #6)
Provid
e details regarding the need for this leave:
I atte
st that the above information is accurate and complete. I understand falsification of any
information given may lead to disciplinary action.
Employee Signature:
Dat
e:
EPSL and Accrued Leave Elections (Required)
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Select
below to indicate how you want your pay to be calculated based on your qualifying need for leave (please
select only one):
OPTIONS FOR QUALIFYING NEEDS 1, 2 & 3 (Two Weeks/Max $511 per day):
Emergency Paid Sick Leave Only
Emergency Paid Sick Leave plus use of your available accrued leave to receive full regular pay
OPTIONS FOR QUALIFYING NEEDS 4, 5 & 6 (Two Weeks - including 1
st
two weeks of EFMLA - at 2/3 pay/ Max $200
per day)
Unpaid (will not reduce available EPSL or your available accrued leave)
Emergency Paid Sick Leave only (will not reduce your available accrued leave)
Employee’s own accrued leave only (will not reduce available EPSL)
Emergency Paid Sick Leave plus use of your available accrued leave to receive full regular pay
OPTIONS FOR QUALIFYING NEED 5 (Weeks 3-12 as available at 2/3 pay/Max $200 per day)
EFMLA only (will not reduce employee’s available accrued leave, limited to 2/3s of regular pay
with $200 daily cap)
EFMLA plus use of your available accrued leave to receive full regular pay
If you elected to use your available accrued leave to receive full regular pay, based upon your own accrued leave,
indicate which leave type (Annual or Sick) you would like to use first as allowed by Civil Service Rule 27:
1
st
Used:______________ 2
nd
Used:_______________
If Compensatory Time Off is available it will automatically be used before Annual Leave or Sick Leave.
Employee Signature Date::
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