OKLAHOMA BAPTIST UNIVERSITY
Families First Coronavirus Response Act Sick Pay &/or Leave Request Form
Name: ID #:
Date(s) of leave requested:
Type of leave requested: ☐ Paid sick leave ☐Expanded Family and Medical Leave
Reason for leave (check one):
☐ Subject to a Federal, State, or local quarantine or isolation order related to COVID-19
Name of government entity that issued the order:
☐ Advised by a health care provider to self-quarantine due to concerns related to COVID-19
Name of health care provider who gave advice:
☐ Experiencing symptoms of COVID-19 and is seeking a medical diagnosis
☐ Caring for an individual who is subject to a quarantine order or who has been advised by a health
care provider to self-quarantine
☐ Providing care for my child due to school or place of care closure, or the child-care provider of
my child is unavailable, due to COVID-19 precautions
Name of child being cared for:
Name of school, place of care, or child-care provider that is closed or unavailable:
Is there any other suitable person available to care for child? ☐Yes ☐No
☐ Experiencing other substantially similar condition specified by the Secretary of Health and
Human Services in consultation with the Secretary of the Treasury and the Secretary of Labor.
☐By checking the box I am stating I am unable to work because of the reason checked above.
Employee Signature:
Date:
Supervisor signature:
Date:
HR ☐ Payroll ☐
