Leave Request Form Families First Coronavirus Response Act (FFCRA)
Employee ID Number:
Hire Date:
Supervisor Name:
Today’s Date:
Effective April 1, 2020, all employees at the University of Colorado Boulder will be eligible for paid administrative leave for any of the
situations outlined below through May 16, 2020.
I am reques
ting leave for one of the following reasons (please check one):
I am unable to fulfil my work duties due to one of the following reasons:
Note: Employees on soft funding (sponsored projects, grants, service contracts, internal service centers, and research funded by gifts) are
eligible pending approval from their faculty sponsor (if applicable), Chair or Institute Director, and their Dean.
My job duties are not conducive for remote working
I do not have access to laptops, home internet, etc.
I am a new employee whose onboarding or training can’t be finalized remotely
I have a severe underlying medical condition as defined by the CDC.
Employees who are requesting leave due to an underlying medical condition may be required to provide applicable medical
I am unable to fulfil my work duties because:
[FFA 1] I am subject to a federal, state, or local (including CU) quarantine or isolation order related to
[FFA 2] I have been advised by a health care provider to self-quarantine because of COVID-19;
[FFA 3] I am experiencing symptoms of COVID-19 and am seeking a medical diagnosis;
[FFA 4] I am caring for an individual subject or advised to quarantine or isolation;
[FFA 6] I am experiencing substantially similar conditions as specified by the Secretary of Health and Human
Services, in consultation with the Secretaries of Labor and Treasury.
[FFA 5] I am unable to work or telework (with Employee Relations or department HR approval) due to a need to care
for a child under 18 years of age because that child's school or place of care has closed or the child's child care
provider is unavailable due to a public health emergency with respect to COVID-19.
Additional Information (this section should only be completed if you selected the FFA 5 option):
I am requesting block leave beginning on and ending on
I am requesting intermittent leave for up to days per week.
Do you have a spouse or partner that works for CU and will also be requesting leave?
Have you utilized FMLA within the past 12 months?
Yes No
Please submit this leave request form to HRSC@colorado.edu
and copy your supervisor. Human Resources will contact you
within 5 business days.
Employee Si
gnature Supervisor Signature
3100 Marine Street, Third Floor
303 492 6475
565 UCB
Boulder, Colorado 80309-0565
303 492 4693
Name of the child being cared for:
Name of the school, place of care, or child care provider that has closed or become unavailable:
Explanation as to why there is no other suitable person available to care for child:
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