MSJC Emergency Sick Leave Request Form Page 1
Mt. San Jacinto Community College District
Employee Name:__________________________________________ Employee ID #:______________________
Date of Request:__________________________________________ Work Schedule:_____________________
Dept./Job Title:___________________________________________ Start Date of Leave:__________________
Supervisor:_______________________________________________ Expected End Date of Leave:___________
I am unable to work or telework and request to use COVID-19 Emergency Paid Sick Leave for the following
reason (check one):
1. I am subject 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 related to COVID-19.
3. I am experiencing symptoms and is seeking a medical diagnosis related to COVID-19.
4. I am caring for an individual subject to:
an order described in (1) or self-quarantine as described in (2)
5. I am caring for my child(ren) whose school or childcare is closed or unavailable due to COVID-19
related reasons.
6. I am experiencing any other substantially-similar condition specified by the U.S. Department of
Health and Human Services.
Proof of eligibility may be required
Method of Leave Requested:
A. Consecutive Leave (Start Date through End Date):_____________________________________
B. Intermittent or Reduced Leave Schedule*
*Intermittent or Reduced Leave scheduling will be determined on a case-by-case basis. Unless you are
teleworking, once you begin taking paid sick leave for one or more of these qualifying reasons, you must
continue to take paid sick leave each day until you either (1) use the full amount of paid sick leave or (2) no
longer have a qualifying reason for taking paid sick leave. This limit is imposed because if you are sick or
possibly sick with COVID-19, or caring for an individual who is sick or possibly sick with COVID-19, the
intent of the Families First Coronavirus Response Act (FFCRA) is to provide such paid sick leave as necessary
to keep you from spreading the virus to others.
Requests must be routed to Human Resources as soon as possible for processing and Payroll reporting. Attach a
copy of employee’s current work schedule to this request. Confirmation of eligibility of COVID-19 FMLA leave will
be issued by Human Resources and communicated via letter.
__________________________________________________ ______________________
Employee Signature Date
HR Processing
Payroll copy E2=__________hours
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