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:
Supervisor signature:
HR Payroll
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