Pasadena Area Community College District/ Office of Human Resources
IND-REQ03 FFCRA Request for Time Off Form
Page 1 of 1 - 1570 East Colorado Boulevard Pasadena, California 91106-2003 (626) 585-7388 FAX (626) 585-7924
Office of Human Resources
REQUEST FOR TIME OFF UNDER FAMILIES FIRST CORONAVIRUS RESPONSE ACT (FFCRA)
Please note that fields with * are required
*Name *Position Title:
(Please print)
*Supervisor’s Name: *Department:
(Please print)
I am requesting FFRCA Leave for the following reason (please only check one):
I am subject to a Federal, State, or local quarantine or isolation order related to COVID-19.
I have been advised by a health care provider to self-quarantine due to concerns related to COVID-19.
I am experiencing symptoms of COVID-19 and seeking a medical diagnosis.
I am caring for an individual who is subject to a Federal, State, or local quarantine or isolation order related to COVID-19 or been
advised by a health care provider to self-quarantine due to concerns related to COVID-19.
I am caring for a son or daughter whose school or place of care has been closed, or whose child care provider is unavailable, due to
COVID-19 precautions.
Child’s name: Care Provider:
(your son or daughter who you need to care for) (School, place of care, or child care provider that is
closed due to Covid-19)
I certify that there is no other suitable person available to care for my child:
I am experiencing other conditions substantially similar to COVID 19.
Other reasons. Please describe:
*Requested Start Date: Expected End Date:
(If known)
I acknowledge that my typed signature here represents my live signature for the purpose of this document and that I may be required to
submit documentation and/or certifications supporting my need for FFCRA leave.
*Employee signature: *Date:
FOR HUMAN RESOURCES USE ONLY
Approval: Yes No Date:
Notes:
HR Designee’s Name (Please print):
click to sign
signature
click to edit
![]()
