Rialto Unified School District | 182 E. Walnut Avenue Rialto, CA 92376 | tel: (909) 820-7700 ext. 2400 | fax: (909) 873-9376 | kec.rialto..k12.ca.us
COVID-19 Supplemental Paid Sick Leave
You may be approved to use COVID-19 Supplemental Paid Sick Leave if you are unable to work or telework for specified
reasons related to COVID-19. This will not come out of the employee’s sick time. These provisions will apply from
January 1, 2021 through September 30, 2021.
Employee Name: Phone:
Work site: Job Title: Work Hours:
First day off work: Last day off work:
Qualifying Reason for Leave (10 days maximum): (employee will be paid their regular rate of pay, up to $511/day**)
1. You were advised by a health care provider to self-quarantine related to COVID-19.
2. You are experiencing COVID-19 symptoms and seeking a medical diagnosis.
3. You are attending a vaccine appointment or cannot work or telework due to vaccine-related symptoms.
4. You are caring for a family member who is subject to a COVID-19 quarantine or isolation period or has been advised by a
healthcare provider to quarantine due to COVID-19. (“Individual” means the employee’s immediate family member, a
person who regularly resides in the employee’s home.)
(For reasons 1,2,3,4) Employee must submit quarantine order/test results/vaccination proof to be approved to use COVID-19
Supplemental Paid Sick Leave.
Employee’s Signature: ____________________________________ Date: ___________________
5. You are caring for a child whose school or place of care is closed or unavailable due to COVID-19 on the premises.
Name of child/children:_______________________________ School/Place of Care:_______________________
School/Place of Care Phone Number:_____________________
I attest that no other suitable person will be caring for my child/children listed above during the period for which I am taking leave
under COVID-19 Supplemental Paid Sick Leave.
Employee’s Signature: ____________________________________ Date: ___________________
** I request to use my accrued, unused paid time off to supplement my pay under SPSL so that I can receive my normal full pay.
For Personnel use only below this line:
Qualifies - Dates approved: __________________________________________ Does Not Qualify
Eligibility Verified by: ____________________________________________ Date: ____________________