Fillable REQUEST FOR 2022 COVID-19 SUPPLEMENTAL PAID SICK LEAVE (County of Los Angeles / Internal Services Department)

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REQUEST FOR 2022 COVID-19 SUPPLEMENTAL PAID SICK LEAVE (County of Los Angeles / Internal Services Department)

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COUNTY OF LOS
ANGELES
Department of Human Resources | Occupational Health/Leave Management
Countywide Protected Leaves of Absence
REQUEST FOR 2022 COVID-19
SUPPLEMENTAL PAID SICK LEAVE
Instructions:
1. All employees may request paid time off related to COVID-19 under California Senate
Bill 114 – COVID-19 Supplemental Paid Sick Leave (SPSL). A description of this
leave is provided on page 2 of this document.
2. To request this time off, employees should complete the “Request For 2022
COVID-19 Supplemental Paid Sick Leave (SB 114).” The form is available as a PDF
document or as a PDF fillable document on the Department of Human Resources
website at https://employee.hr.lacounty.gov/covid19-supplemental/.
3. Employees should submit the completed request form to their department’s Human
Resources Office.
• A list of all Departmental Human Resources Managers can be found HERE.
• Departmental Human Resources Offices will provide employees with an e-mail
address that can be used to electronically submit the completed request form.
If the request form is completed electronically and the employee is unable to
submit the form with their electronic signature applied, the employee may
submit the completed, unsigned request form as an attachment to an e-mail
from their work or personal e-mail address. The information in an employee’s
submission of a completed and unsigned request form from the employee’s
e-mail address will be deemed as their certification of the information listed in
the form.
• Unsigned request forms may not be submitted from an e-mail address that
does not belong to the employee.
COUNTY OF LOS
ANGELES
Department of Human Resources | Occupational Health/Leave Management
Countywide Protected Leaves of Absence
COVID-19 SUPPLEMENTAL PAID SICK LEAVE/SB 114
Effective
Date
February 19, 2022, retroactive to January 1, 2022
Who is
Eligible
All County of Los Angeles employees
Amount of
Leave in
Each Bank
Full-Time Employees:
Up to 40 hours
Part-Time Employees:
Employees with a regular weekly schedule: an amount equal to one regular
workweek.
Employees with irregular schedules or variable hours:
(1) Calculating the average number of hours the employee worked each day
over the last 6 months and multiplying the result by 7 to get the amount of 2022
COVID-19 SPSL benefit time.
(2) If the employee worked fewer than (six) 6 months, then, the allocation would
be determined by calculating the average hours worked for the entire
employment period and multiplying the daily average by a factor of seven (7).
(3) If an employee worked variable hours and only worked for seven (7) days
or less, the employee receives an amount of 2022 COVID-
19 SPSL benefit
time equal to the total hours worked for the employer.
Firefighters:
Firefighters who were scheduled to work more than 40 hours in the workweek
before they take 2022 COVID-19 SPSL are entitled to the total number of hours
the employee was scheduled to work that workweek.
Qualifying
Reasons for
2022
COVID-19
SPSL
The Employee is unable to work or telework due to any of the following reasons:
(1) They are subject to a federal, state, or local quarantine or isolation order or
guidelines related to COVID-19. If the employee is subject to more than
one quarantine or isolation period,
the employee will be permitted to use
COVID-19 SPSL for the minimum quarantine or isolation period under the
order/guidelines that provides the longest such minimum period;
(2) The employee has been advised by a health care provider to
self-quarantine or self-isolate due to concerns related to COVID-19;
(3) The employee is attending an appointment
for themselves or a family
member to receive a vaccine or a vaccine booster
for protection against
contracting COVID-19;
COUNTY OF LOS
ANGELES
Department of Human Resources | Occupational Health/Leave Management
Countywide Protected Leaves of Absence
COVID-19 SUPPLEMENTAL PAID SICK LEAVE/SB 114
(4) The employee is experiencing symptoms, or caring for a family member
experiencing symptoms, related to a COVID-19 vaccine or vaccine booster
that prevents the employee from being able to work or telework;
• For
each vaccination or vaccine booster, the maximum amount of
supplemental paid sick leave that can be used is three (3) days or
24 hours unless the employee provides verification from a health care
provider that the covered employee or their family member is continuing
to experience symptoms related to a COVID-
19 vaccine or vaccine
booster. This includes the time used to get the vacc
ine or vaccine
booster.
(5) The employee is experiencing symptoms of COVID-
19 and seeking a
medical diagnosis;
(6) The employee is caring for a family member who is subject to an order or
guidelines described in Qualifying Reason #1 or who has been advised to
self-quarantine or self-isolate, as described in Qualifying Reason #2;
(7) The employee is caring for a child whose school or place of care is closed
or otherwise unavailable for reasons related to COVID-19 on the premises;
or
(8)
The employee or a family member for whom the employee is providing
care tests positive for COVID-19. The employee must attest to a positive
COVID-19 test result when requesting SPSL. The County may request
proof of a positive COVID-19 test result.
Availability
of 2022
COVID-19
SPSL Hours
2022 COVID-19 SPSL is broken out into two (2) separate leave buckets:
In the first bucket, full-time employees are entitled to 40 hours of COVID-19 SPSL
for qualifying leave reasons one (1) through seven (7).
Upon providing an attestation of a positive COVID-
19 test result, hours will be
added to the second bucket. Full-time employees are entitled to an additional
40 hours of COVID-19 SPSL for Qualifying Reason #8. The County may request
proof of a positive COVID-19 test result.
An employee is not required to exhaust the first bucket of 40 hours of SPSL before
requesting to use the second bucket of 40 hours of SPSL available for a
COVID-19 positive test result.
Pay
Qualifying employees are paid at their regular rate of pay.
Relationship
with Other
Leaves
Employees are not required to use other accrued leaves prior to using this leave.
Use of this leave does not count against an employee’s other paid leave accrual
balances, such as accrued vacation leave, sick leave, etc.
COUNTY OF LOS
ANGELES
Department of Human Resources | Occupational Health/Leave Management
Countywide Protected Leaves of Absence
COVID-19 SUPPLEMENTAL PAID SICK LEAVE/SB 114
Request for
Approval
Employees requesting approval for 2022 COVID-19 SPSL may submit the request
form to their department’s Human Resources Office.
SPECIAL NOTE FOR DHS EMPLOYEES
Please submit the request form to: COVIDpay@dhs.lacounty.gov
When the need for leave is foreseeable, employees should
notify their
department’s Human Resources Office of the need for leave as soon as possible.
SPSL
Expiration
2022 COVID-19 SPSL is available until September 30, 2022. An employee who is
taking SPSL at the time of expiration may be permitted to take the full amount of
SPSL.
COUNTY OF LOS
ANGELES
Department of Human Resources | Occupational Health/Leave Management
Countywide Protected Leaves of Absence
REQUEST FOR 2022 COVID-19
SUPPLEMENTAL PAID SICK LEAVE
In order to be eligible for this leave, you must be a Los Angeles County employee and be unable
to work or telework due to any of the qualifying reasons listed in Senate Bill 114.
Employee Information
Employee First Name & Last Name
Employee Number
Employee’s Department
Payroll Title
Personal E-mail Address
Work E-mail Address
Home Telephone
Cell Telephone
Supervisor Information
Name
Title
E-mail Address
Work Telephone
SECTION 1: EMPLOYEE LEAVE REQUEST
1. I am requesting 2022 COVID-19 Supplemental Paid Sick Leave for the following
dates:
FROM: TO:
2. I am requesting 2022-COVID-19 Supplemental Paid Sick Leave as follows (choose
one):
_____ Continuous Leave
_____ Intermittent Leave
For intermittent leave requests, please provide the details of the requested leave
schedule:
COUNTY OF LOS
ANGELES
Department of Human Resources | Occupational Health/Leave Management
Countywide Protected Leaves of Absence
Employee Information
Employee First Name & Last Name
Employee Number
3. Check in left column ALL qualifying reasons for leave request:
I am subject to quarantine or isolation period related to COVID-19 as defined by an order or
guidelines issued by the State Department of Public Health, the federal Centers for Disease
Control and Prevention, or a local health officer.
Indicate which Government Agency issued the order or guidelines:
_____ Federal Centers for Disease Control and Prevention
_____ State of California Department of Public Health
_____ County of Los Angeles Health Officer
_____ Other __________________________________________________________
I was advised by a health care provider to self-quarantine or self-isolate due to concerns
related to COVID-19.
Provide name of health care provider that advised you to self-quarantine or self-isolate:
_____________________________________________________________________
I am attending an appointment for myself or a “covered” family member to receive a
vaccine or vaccine booster for protection against contracting COVID-19.
I am experiencing symptoms, or I am caring for a qualified family member experiencing
symptoms, related to a COVID-19 vaccine or vaccine booster that prevents me from being
able to work or telework.
I am experiencing symptoms of COVID-19 infection and seeking a medical diagnosis.
I am caring for a qualified family member who is subject to an order or guidelines described
in Qualifying Reason #1 or who has been advised to self-quarantine or self-
isolate, as
described in Qualify
ing Reason #2. Provide name and relationship to qualified family
member:
COUNTY OF LOS
ANGELES
Department of Human Resources | Occupational Health/Leave Management
Countywide Protected Leaves of Absence
Employee Information
Employee First Name & Last Name
Employee Number
I am caring for a child whose school or place of care is closed or otherwise unavailable for
reasons related to COVID-19 on the premises.
Provide child’s name and school/place of care that is closed due to COVID-
19 related
reasons.
________________________________________________________________________
I attest that I tested positive for COVID-19, or I am caring for a qualified family member who
tested positive for COVID-19. I understand that the County may require evidence of a
positive COVID-19 test result.
Provide the name(s) and relationship(s) to qualified family member(s):
________________________________________________________________________
Provide date of positive COVID-19 test results:
_________________________________________
COMPLETE SECTION 4 ONLY IF YOU ARE REQUESTING
TO AMEND A PREVIOUSLY SUBMITTED TIMECARD FOR LEAVE TAKEN
4. I was unable to work or telework and used my accrued leave benefit time or had
unpaid absences because (check all that apply):
I was subject to a federal, state, or local quarantine or isolation order related to COVID-19.
I was advised by a healthcare provider to self-quarantine or self-
isolate due to concerns
related to COVID-19.
I attended an appointment for myself or a qualified family member to receive a vaccine or a
vaccine booster for protection against contracting COVID-19.
I was experiencing symptoms, or caring for a qualified family member experiencing
symptoms, related to a COVID-19 vaccine or vaccine booster.
COUNTY OF LOS
ANGELES
Department of Human Resources | Occupational Health/Leave Management
Countywide Protected Leaves of Absence
Employee Information
Employee First Name & Last Name
Employee Number
4. I was unable to work or telework and used my accrued leave benefit time or had
unpaid absences because (check all that apply) (continued):
I was experiencing symptoms of COVID-19 infection and seeking a medical diagnosis.
I was caring for a qualified family member who was subject to an order or guidelines as
described in Qualifying Reason #1, or who was advised to self-quarantine or self-isolate, as
described in Qualifying Reason #2.
I cared for my child whose school/place
of care was closed or unavailable for reasons
related to COVID-19 on the premises.
I attest that I tested positive for COVID-19, or a qualified family member I provided care for,
tested positive for COVID-19. I understand that the County may require evidence of a
positive COVID-19 test result.
Provide the name of your qualified family member, and your relationship to this person:
_________________________________________________________________
Certification:
I hereby request leave as indicated above, and certify that such leave is requested for the
purpose(s) indicated. I understand that I must comply with my employing department's
procedures for requesting leave (and provide additional documentation, including medical
certification, if applicable) and that falsification of any information in this form may be grounds for
disciplinary action, up to and including discharge. I understand and fully acknowledge that,
should an overpayment occur, I am required to repay the number of hours of paid leave I was not
entitled to.
Employee Printed Name Employee Number
Employee Signature Date
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COUNTY OF LOS
ANGELES
Department of Human Resources | Occupational Health/Leave Management
Countywide Protected Leaves of Absence
FOR DEPARTMENTAL USE ONLY
INDICATE DISPOSITION OF REQUEST
This request is approved as requested.
This request is approved with the following modification:
This request is not approved because:
The employee did not provide a qualifying reason covered by SB 114.
Other:
AUTHORIZATION
Department Head/Designee Printed Name
Department Head / Designee Signature Date
S:\DHRSec\_OHLM\OCCUPATIONAL HEALTH - LEAVE\SPSL II Leave Request Form (Fillable) Final 3 1 22.docx
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REQUEST FOR 2022 COVID-19 SUPPLEMENTAL PAID SICK LEAVE (County of Los Angeles Internal Services Department)

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Completed 9 June 2022

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