REQUEST FOR EMERGENCY FAMILY MEDICAL LEAVE ACT
Employee Name: __________________________________ Employee ID#: ______________________
Site/Department: ____________________________ Position Title: _____________________________
REQUEST FOR LEAVE
My signature on this form indicates that I am requesting leave under the Emergency Family Medical Leave
Act (EFMLA) in order to care for my minor or disabled child(ren) whose school(s) or place(s) of care is/are
closed or child care provider(s) is/are unavailable due to COVID-19 related reasons.
I understand that I must submit supporting documentation (see EFMLA Supplemental Information Form) of my
need for EFMLA leave along with this completed form in order to qualify for EFMLA leave, including:
1. Name(s) and age(s) of minor or disabled child(ren) being cared for;
2. Copy of official notice of school or child care closure(s) due to COVID-19 related reasons (copy of website or email
notice is acceptable);
3. Written statement that I am unable to work, including telework with or without flexible scheduling, for the qualifying
reason stated above and that no other suitable person is available to care for the child(ren) during the period
of requested leave. Note: If the care is for child(ren) over the age of 14 during daylight hours, include a statement
of special circumstances requiring such care.
METHOD OF EFMLA LEAVE REQUESTED
A. ______ Consecutive leave (maximum 12 weeks of EFMLA leave)
B. ______ Intermittent or reduced leave schedule (specify requested schedule below)
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Date leave is to begin: ______________________ Date leave is to end: _____________________
Return to work date: ________________________
REQUEST TO SUBSTITUTE PAID LEAVE FOR FIRST TWO WEEKS OF UNPAID EFMLA LEAVE
I understand that the first two (2) weeks of EFMLA leave is not paid. I understand that I may substitute
Emergency Paid Sick Leave, accrued vacation, unused personal necessity leave (maximum 7 days), or
other forms of accrued leave for the first two (2) weeks of unpaid EFMLA leave.
I request the following leave(s) to run concurrently with the first two (2) weeks of EFMLA leave:
A. ______ Emergency Paid Sick Leave: # days requested:_______________ (maximum 10 days)
B. ______ Accrued Vacation: # days requested:_______________ (maximum 10 days)
C. ______ Personal Necessity Leave: # days requested:_______________ (maximum 7 days)
D. ______ Other available leave Specify:____________________________________________
I understand that if the duration of my family/medical leave does not exceed 12 weeks, I will be returned
to my same, equivalent, or comparable position.
Employee Signature: _________________________________________ Date: ___________________
Employee Address: ___________________________________________________________________
___________________________________________________________________
Employee Phone Number: ________________________________ Rev 4-10
Rev 4-10
EMERGENCY FAMILY MEDICAL LEAVE ACT (EFMLA)
SUPPLEMENTAL INFORMATION FORM
Employees requesting Emergency Family Medical Leave Act (EFMLA) leave under the Families First
Coronavirus Response Act (FFCRA) must provide the District with supporting information/documentation
regarding the qualifying reason for the leave.
Complete Sections 1-3 below and attach supporting documentation when required.
Section 1: Employee Information
Employee Name: ________________________________ Employee ID#: ______________________
Site/Department: ___________________________ Position Title: _____________________________
Section 2: Qualifying Reason for Emergency FMLA (check box/fill in)
I am unable to work, including telework with or without flexible scheduling, for the following reason:
A. I am caring for my child
1
whose school or place of care has been closed or whose
childcare provider is unavailable for reasons related to COVID-19.
Name(s) and age(s) of child(ren) for whom such care is necessary. Only include children
under the age of 18, unless child(ren) is/are incapable of self-care because of a mental or
physical disability:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Name of the school(s), place(s) of care, or childcare provider(s) unavailable for reasons
related to COVID-19:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Attach copy or printout of notice(s) of closure or statement(s) of unavailability.
For care of child(ren) ages 15-17 during daylight hours, describe special circumstances
requiring such care:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
1
“Child” means children under 18 years of age, or 18 years of age and older and incapable of self-care
because of a mental or physical disability.
Section 3: Certification
I understand that I must provide the above requested information in order for my request for leave under
the Emergency Family Medical Leave Act to be considered. If I need to make any changes to the
information submitted on this form, I may be asked to complete and submit a new form.
I attest that no other suitable person is available to care for my child/children listed above during the period
for which I am requesting leave under EFMLA.
I understand that employees receive up to 12 workweeks of protected leave under EFMLA, and that if an
employee has already used FMLA leave during the applicable 12-month period, the time available for
EFMLA will be reduced by the amount of FMLA already used.
Employee Signature: ___________________________________ Date: ____________________
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome