Fillable REQUEST FOR TEMPORARY PAID ADMINISTRATIVE LEAVE (CPAL) CORONAVIRUS (California State University, Los Angeles)

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REQUEST FOR TEMPORARY PAID ADMINISTRATIVE LEAVE (CPAL) CORONAVIRUS (California State University, Los Angeles)

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REQUEST FOR TEMPORARY PAID ADMINISTRATIVE LEAVE (CPAL)
CORONAVIRUS PANDEMIC (COVID-19)
Employee Name:
Employee ID:
Job Title:
Division/Department:
Classification:
Full-Time:
Part-Time:
Exempt:
Non-Exempt:
Supervisor Name:
Supervisor email/Ext.
Date Requested:
Date of Requested Extension (if applicable):
In accordance with HR Letter 2020-04, most employees (exempt and non-exempt) including student employees are eligible to receive a
one-time allotment of up to 32 days (256 hours) of paid administrative leave from March 23, 2020, through December 31, 2020, that
can only be used due to COVID-19 related absences, subject to the following conditions:
• All hours must be used by close of business on December 31, 2020 at which time any remaining allotted hours will expire.
• The hours may be used at any time during this designated period including intermittently, in consultation with the appropriate
administrator, provided that such use shall not adversely affect the delivery of essential university services.
• The number of hours of paid administrative leave for employees who work less than full-time shall be prorated according to the
employee’s percent or time base of their appointment.
PERMISSIBLE USE OF LEAVE
Select at
least One (1)
Qualifying Reasons to Use Coronavirus Pandemic (COVID-19) Temporary Paid Administrative Leave
I am unable to work due to my own COVID-19-related illness.
I am unable to work or work remotely due to my family member’s COVID-19 related illness. (For purposes of this
paid leave, family member includes those I would normally be able to use sick leave for.)
I am unable to work because I have been directed by my healthcare provider not to come to the worksite for
COVID-19-related reasons.
I am unable to work because I have been directed by my appropriate administrator not to come to the worksite
and it is not operationally feasible for me to work remotely.
I am unable to work due to a COVID-19-related school or daycare closure and I am required to be at home with a
child or dependent, and it is not operationally feasible for me to work remotely or in conjunction with the childcare
commitment.
REQUEST FOR DATES OF CORONAVIRUS PANDEMIC (COVID-19) TEMPORARY PAID ADMINISTRATIVE LEAVE
Month
Dates Requested (Additional detail may be attached to
this form E xempt employees must use time in full day
increments if not covered under FML.)
Total Number
of Hours
Requested
Total Number of
Hours Used Prior
to this Request
Total Number of
Hours Remaining
in Allotment
Total Hours
SIGNED AND AGREED BY:
To the best of my knowledge and belief, I certify that the facts stated are accurate and in full compliance with CPAL policy
requirements. I understand I may be asked to substantiate the reason for the leave in accordance with current Bargaining Unit
Contracts and/or CSU Policies.
Employee Name:
Signature:
Date:
I approve the use of temporary paid administrative leave as indicated above
Dean/Director:
Appropriate Administrator Name:
HR/Academic Personnel Designee Name:
Signature:
Signature:
Date:
Date:
Signature: Date:
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Request for Dates of Coronavirus Pandemic (COVID-19) Temporary Paid Administrative Leave
Detail by Month
Month: ___________________ Pay Period _________________
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Pay Period _________________
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Month: ___________________
Pay Period _________________
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Month: ___________________
Pay Period _________________
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REQUEST FOR TEMPORARY PAID ADMINISTRATIVE LEAVE (CPAL) CORONAVIRUS (California State University, Los Angeles)

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Completed 28 January 2021

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