Patricia Keppler, Personnel & Safety Director
Leana Testani, Assistant Director of Personnel & Safety
City Hall ▪ 38 Hawley Street ▪ Binghamton, NY 13901 ▪(607) 772-7008 ▪www.binghamton-ny.gov
Department of Personnel and Safety
Employee Request for Paid Sick and Family Leave under NYS Quarantine Law
“Employee Benefits Quarantine” (as of 3/18/20)
I am requesting Paid Sick and Family Leave under the New York State Employee Benefits Quarantine Law (Legislative
Bill 12052-01-0, passed March 18, 2020) (“NYSQPL”):
A. Dates. I request leave for the following dates: __________________________
B. Certification. I certify that I am unable to either work or telework from home based on the following Qualifying
Reason(s) below: [Initial the Qualifying Reasons that apply.]
_____ (1) The employee is under a mandatory or precautionary order of quarantine or isolation issued by the State,
New York State Department of Health, local Board of Health, or other authorized government entity.
_____ (2) The employee’s child is under a mandatory or precautionary order of quarantine or isolation issued by the
State, New York State Department of Health, local Board of Health, or other authorized government entity.
_____ (3) The employee’s child’s school is under a mandatory or precautionary order of quarantine or isolation issued
by the State, New York State Department of Health, local Board of Health, or other authorized government
entity.
C. Documentation.
1
I have provided the following documents in support of my request [List and Attach]:
________________________________________________________________________
Note: If you are eligible for Expanded FMLA under the FFCRA, you must provide additional documentation
required by the FMLA.
2
Signature: ______________________________ Date: ____________, 2020
Name:
1
Per US DOL: “If one of your employees takes paid sick leave under the Emergency Paid Sick Leave Act, you must require your
employee to provide you with appropriate documentation in support of the reason for the leave, including: the employee’s name,
qualifying reason for requesting leave, statement that the employee is unable to work, including telework, for that reason, and the
date(s) for which leave is requested. Documentation of the reason for the leave will also be necessary, such as the source of any
quarantine or isolation order, or the name of the health care provider who has advised you to self-quarantine.”
2
Per US DOL: “If one of your employees takes expanded family and medical leave to care for his or her child whose school or place
of care is closed, or child care provider is unavailable, due to COVID-19, under the Emergency Family and Medical Leave Expansion
Act, you must require your employee to provide you with appropriate documentation in support of such leave, just as you would for
conventional FMLA leave requests.”
