Fillable Name E Number Address City/State/Zip Home Phone Cell (East Tennessee State University)

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Name E Number Address City/State/Zip Home Phone Cell (East Tennessee State University)

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File type: PDF

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Department of Human Resources
Published 04/06/2020
Request for use of Emergency
Family Medical Leave or
Emergency Paid Sick Leave
Name
E Number
Address
City/State/Zip
Home Phone Cell Phone
Email
I am requesting leave due to:
☐ Being subject to a governmental quarantine or isolation due to COVID-19
☐ Being advised by a healthcare provider to self-quarantine due to COVID-19
☐ Experiencing the symptoms of COVID-19 and am seeking a diagnosis
☐ Caring for an individual subject to or advised to quarantine or isolate
☐ Caring for a child whose school or childcare is closed or unavailable due to
COVID-19
Ages of children:
Are you the sole provider for your children? ☐ Yes ☐ No
☐ Experiencing substantially similar conditions as those specified by the
Secretary of Health and Human Services in consultation with the Secretaries
of Labor and Treasury
Please provide an explanation of the documentation you provide along with this
request:
I am requesting this leave from: until
Begin date End date
Employee Signature Date
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signature
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Department of Human Resources
Published 04/06/2020
Request for use of Emergency
Family Medical Leave or
Emergency Paid Sick Leave
Supervisor Must Complete this Section
Have you discussed the option to telecommute, flex the work schedule, or
provide an alternate shift with this employee?
☐ Yes ☐ No
Are you able to provide alternate work to your employee?
☐ Yes ☐ No
If you answered “no,” please explain why alternate work is not available to your
employee:
Supervisor Signature Date
This section for HR/Payroll use only
This leave request is ☐ Approved ☐ Denied
Employee Status ☐ Full Time ☐ Part Time
Hourly Rate of Pay Avg Hrs Worked per Week
Pay employee ☐ 100% of regular pay capped at $511 per day
☐ 2/3 of regular pay capped at $200 per day
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Name E Number Address CityStateZip Home Phone Cell (East Tennessee State University)

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Completed 20 August 2020

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