Fill - Free fillable REQUEST FOR EMERGENCY FAMILY MEDICAL LEAVE ACT PDF form

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

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:

_______________________________________________________________________

“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: ____________________

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Fillable REQUEST FOR EMERGENCY FAMILY MEDICAL LEAVE ACT

Fill Online, Printable, Fillable, Blank REQUEST FOR EMERGENCY FAMILY MEDICAL LEAVE ACT Form

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