MSJC COVID-19 FMLA Leave Form Page 1
Mt. San Jacinto Community College District
REQUEST FOR COVID-19 FMLA LEAVE
Employee Name:_____________________________________________ Employee ID #:________________________
Date of Request: _____________________________________________ Work Schedule:_______________________
Department:_________________________________________________ Start Date of Leave:____________________
Job Title:____________________________________________________ Expected End Date of Leave:_____________
I am unable to work or telework and request to use COVID-19 expanded family and medical leave (FMLA) for the
following reason (check one):
I am caring for my child(ren) whose school or place of care is closed (or childcare provider is unavailable) due to
COVID-19 related reasons.
Proof of school/place of care closure 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. Please note, intermittent
expanded family and medical leave will only be considered if you and your manager have agreed upon a tentative
schedule and you include that tentative schedule below. For example, you and your manager could tentatively
agree to a Tuesdays and Thursdays work schedule while you take expanded family and medical leave on Mondays,
Wednesdays, and Fridays. Attach a copy of employees current work schedule to this request.***
COVID-19 FMLA GRID**
HOURS
MONDAY
TUESDAY
WEDNESDAY
THURSDSAY
FRIDAY
Example
7:30 AM 12 PM
TELEWORK
COVID-19 FMLA
TELEWORK
COVID-19 FMLA
TELEWORK
Example
12:30 5 PM
COVID-19 FMLA
COVID-19 FMLA
COVID-19 FMLA
COVID-19 FMLA
Not scheduled
Total FMLA hours
**Utilize grid to indicate times worked and times for intermittent COVID-19 FMLA leave. Please use another sheet of paper if
additional dates/times are needed to reflect your schedule under intermittent COVID-19 FMLA leave.
***Confirmation of eligibility of COVID-19 FMLA leave will be issued by Human Resources and communicated via letter.
__________________________________________________ ______________________
Supervisor Signature Date
__________________________________________________ ______________________
Employee Signature Date
HR Processing
Payroll copy E2=__________hours
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