Distribution: 1. Original - OTM-Employee Records and Transactions Section; 2. Copy 1 - Employee; 3. Copy 2 - School/Office (Page 2 of 2)
Any employee who is unable to work (or telework) due to a need for leave because:
The employee is subject to a Federal, State, or local quarantine or isolation order related to COVID-19.
Employee Records and Transactions Section
P.O. Box 2360 Honolulu, HI 96804
PAID LEAVE FORM
Last Revised: 03/31/2020
Former DOE Form: N/A
Office of Talent Management (OTM)
The employee has been advised by a health care professional to self-quarantine due to concerns related to
The employee is caring for an individual who is subject to an order as described in line 1 or 2 above.
Any employee who has been employed for at least 30 days can take EFMLEA leave if "the employee is unable to
work (or telework) due to a need for leave to care for the son or daughter under 18 years of age of such employee if
the school or place of care has been closed, or the child care provider of such son or daughter is unavailable, due to a
public health emergency."
The EFMLEA allows covered employees to use up to 12 weeks of Family Medical Leave Act ("FMLA") leave. The
first 10 days of EFMLEA leave may be unpaid. However, EFMLEA gives employees the choice to use "any accrued
vaction leave, personal leave, or medical or sick leave" during the initial 10-day period. After the 10-day period has
passed, employers must provide paid leave in an amount not less than two-thirds of an employee's regular rate. (Note:
Employees who would like to supplement the one-third balance with vacation leave, sick leave, or compensatory time
may do so by filling out a G-1 request form.
Read the eligibility requirements, coverage and payment.
If eligible, please check the appropriate box and fill out Application for Leave of Absence (G-1) form or DOE OTM
300-001 - Application ofr Leave of Absence Certificated School-Level Employees.
The employee is experiencing any 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.
Full-time employees receive 80 hours of paid sick leave. Part-time employees are entitled to leave based upon the
average number of hours the part-time employee works over a two-week period. The amount an employee must be
paid depends on the reason they are taking leave:
For reasons 1 - 3 above: Total paid leave at the employee's regular rate of pay.
For reasons 4 - 6 above: Total paid leave at two-thirds of their regular rate of pay. (Note: Employees who
would like to supplement the one-third balance with vacation leave, sick leave, or compensatory time may
do so by filling out a G-1 request form or DOE OTM 300-001 form.)
The employee is experiencing symptoms of COVID-19 and seeking a medical diagnosis.
The employee is caring for the son or daughter of such employee if the school or place of care of the son or
daughter has been closed, or the child care provider of such son or daughter is unavailable, due to COVID-19
STEP 1: ELIGIBILITY REQUIREMENTS, COVERAGE AND PAYMENT
Emergency Family and Medical Leave Expansion Act ("EFMLEA").
Emergency Paid Sick Leave Act ("EPSLA").
Sign the form acknowledging your understanding and agreement with the leave conditions and submit this form to
OTM with the required documents.