Fillable PAID LEAVE FORM Last Revised: 03/31/2020 Former DOE

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PAID LEAVE FORM Last Revised: 03/31/2020 Former DOE

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Distribution: 1. Original - OTM-Employee Records and Transactions Section; 2. Copy 1 - Employee; 3. Copy 2 - School/Office (Page 2 of 2)
INSTRUCTIONS:
Application Process
A.
B.
Any employee who is unable to work (or telework) due to a need for leave because:
1.
2.
3.
4.
5.
6.
●
●
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
COVID-19 EMERGENCY
PAID LEAVE FORM
DOE OTM 300-030
Last Revised: 03/31/2020
Former DOE Form: N/A
DEPARTMENT OF EDUCATION
Office of Talent Management (OTM)
Employee Name:
Date:
School/Office:
Bargaining Unit:
Last
First
MI
The employee has been advised by a health care professional to self-quarantine due to concerns related to
COVID-19.
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.
Contact Phone Number:
Step 1:
Step 2:
Step 3:
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
precautions.
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.
Distribution: 1. Original - OTM-Employee Records and Transactions Section; 2. Copy 1 - Employee; 3. Copy 2 - School/Office (Page 2 of 2)
(Note: Please submit a form G-1 or DOE OTM 300-001 and indicate the type of leave, COVID-19 EMERGENCY PAID
LEAVE/sick or vac or comp time.)
(Note: Please submit a form G-1 or DOE OTM 300-001 and indicate the type of leave, COVID-19 EMERGENCY PAID
LEAVE/sick or vac or comp time.)
Principal/Administrator's Signature
STEP 2:
If eligible, please check the appropriate box.
Emergency Family and Medical Leave Expansion Act ("EFMLEA")
Name of School or Child-Care Facility:
OTM Designee Signature
Date
Date(s) of Leave:
Date(s) of Leave:
I understand that Emergency Paid Leave will cover my full regular rate of pay salary.
I understand that Emergency Paid Leave will cover 2/3 of my regular rate of pay salary.
STEP 3:
I certify that I have read and agree to the above and that the above request is true and accurate. In
addition, I understand my request may be subject to verification by OTM.
I understand that failure to return to work at the end of the leave period will be treated as any other failure to return to duty
at the expiration of the leave.
Employee's Signature
Date
Reasons 4 - 6 apply to you.
DOE OTM 300-020
Last Revised: 03/31/2020
Date
Emergency Paid Sick Leave Act ("EPSLA")
(PLEASE CHECK ONE
BOX)
Reasons 1 - 3 apply to you.
Emergency Paid Leave + 1/3 of compensatory time leave = Regular Salary (100%).
Date (s) of Leave:
I understand that Emergency Paid Leave will not cover my full salary and elect ONE of the following:
Emergency Paid Leave 2/3 of salary.
Emergency Paid Leave + 1/3 of sick leave = Regular Salary (100%).
Emergency Paid Leave + 1/3 of vacation leave = Regular Salary (100%).
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PAID LEAVE FORM Last Revised: 03312020 Former DOE

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Completed 10 November 2020

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