Fillable Request For EPSL And EFMLA Revised 4 9-2020

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Request For EPSL And EFMLA Revised 4 9-2020

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Page 1 of 4
EPSL AND E-FMLA FORM REVISED 04/09/2020
E
MERGENCY PAID SICK LEAVE
And EMERGENCY FMLA REQUEST FORM (COVID-19)
Families First Coronavirus Response Act (FFCRA) provisions applies from April 1, 2020 through December 31, 2020.
S
ection I: EPSL and E-FMLA FORM (COVID-19)
Name: __________________________________________ ______________________ _____________________
Employee ID Number (Contact Phone)
Address:_________________________________________ _____________________________________________
(Street) (City, State, Zip)
Department: _____________________________________ ______________________________________________
(Division/Supervisor) (Department Name)
SE
CTION II: QUALIFYING REASONS FOR EPSL AND E-FMLA
I am requesting EPSL for the following reasons related to COVID-19:
1. ☐ I am subject to a Federal, State, or Local quarantine or isolation order related to COVID-19.
2. ☐ I have been advised by a health care provider to self-quarantine related to COVID-19.
3. ☐ I am experiencing COVID-19 symptoms and seeking medical diagnosis.
4. ☐ I am caring for an individual who is subject to Federal, State, or Local quarantine/isolation order related to COVID-
19 or who has been advised by a health care provider to self-quarantine due to concerns related to COVID-19.
5. ☐ I have a child who is under the age of 18 years of age, whose school or place of care has been closed, or whose
child care provider is unavailable due to a COVID-19 emergency declared by either a Federal, State, or Local
authority.
6. ☐ I am experiencing another substantially similar condition specified by the Secretary of Health and Human Services
in consultation with the Secretary of the Treasury and the Secretary of Labor.
Ty
pe of Leave Request: ☐ Consecutive Leave ☐ Intermittent or Reduced Schedule:
Specify proposed schedule for permitted intermittent leave:
A
bsence Dates: From: ____________________________ To: ____________________________ TOTAL HOURS: _____________
(No intermittent leaves allowed for quarantine, isolation, or symptoms)
SE
CTION III: QUALIFYING REASON FOR E-FMLA ONLY
Employees who are unable to work due to the need to: (a) care for a son or daughter under 18 years of age if the son
or daughter’s school or place of care has been closed, or whose child care provider is unavailable, due to COVID-19-
related reasons, or (b) care for an adult son or daughter (i.e., one who is 18 years of age or older), who (i) has a
mental or physical disability, and (ii) is incapable of self-care because of that disability, when the son or daughter’s
care provider is unavailable due to COVID-19 related reasons.
1. ☐ I have a child who is under the age of 18 years of age, whose school or place of care has been closed, or whose
child care provider is unavailable due to a COVID-19 emergency declared by either a Federal, State, or Local
authority.
Page 2 of 4
EPSL AND E-FMLA FORM REVISED 04/09/2020
SECTION IV: PAY OPTIONS:
E
PSL PAY:
EMERGENCY PAID SICK LEAVE (EPSL): Employees must use the provided 80-hours (pro-rated amount of hours for
part time employees based on average two-week period) EPSL, to the extent such time is available, for the qualifying
reasons related to COVID-19. Exception: If you are requesting leave related to caring for child who is under the age
of 18 years of age, whose school or place of care has been closed, or whose child care provider is unavailable due to a
COVID-19 emergency declared by either a Federal, State, or local authority.
For request specifically related to Child(ren)’s School/Childcare Closure refer to E-FMLA PAY OPTIONS BELOW:
E-F
MLA PAY OPTIONS ONLY
E-FMLA is a job-protected paid leave at two-thirds the employee’s regular rate of pay where an employee, who has
been employed for at least 30 calendar days, is unable to work due to a bona fide need for leave to care for a child
whose school or child care provider is closed or unavailable for reasons related to COVID-19. The paid expanded leave
is in addition to EPSL. SPECIAL NOTE: The E-FMLA is not in addition to existing 12-week leave entitlement under
FMLA. Therefore, if an employee has already used all or a portion of their 12-week entitlement of FMLA leave for
another qualifying reason, the employee is only entitled to use the remaining balance for qualifying reasons under E-
FMLA.
Please review and elect: 1) paid or unpaid options during the initial two weeks (10 days), and 2) elect to coordinate
additional 10 weeks of paid expanded family and medical leave with EPSL, accrued paid leave or wage replacement
benefits to receive your normal bi-weekly rate of pay:
☐ I elect not to use my Emergency Paid Sick Leave and/or accrued paid leave during the initial two weeks of my
protected leave of absence under the E-FMLA provision. I understand that during this initial two weeks, I will be in an
unpaid status.
☐ I elect to use hours of my Emergency Paid Sick Leave and/or hours of accrued paid leave
during my initial two weeks of E-FMLA provision.
☐ I elect to use the following accrued paid leave hours in accordance with the appropriate bargained
memorandum of understanding or Board resolution: ☐ Sick leave ☐ Vacation ☐ Holiday
☐ Comp Time ☐ Other to receive my normal bi-weekly salary.
☐ I understand that I may be eligible for up to an additional 10 weeks of paid expanded family and medical leave
during which, I request to use hours of my Emergency Paid Sick Leave and/or hours of accrued
paid leave concurrently with paid expanded family and medical leave
☐ I understand that I may be eligible for up to an additional 10 weeks of paid expanded family and medical leave
during which, I elect not to use Emergency Paid Sick Leave and/or accrued leave while receiving a wage replacement
benefit to receive my normal bi-weekly salary.
Page 3 of 4
EPSL AND E-FMLA FORM REVISED 04/09/2020
SECTION V: REQUIRED INFORMATION
• If requesting leave for a FEDERAL, STATE OR LOCAL QUARANTINE OR ISOLATION under U.S. Federal, State, or Local
Order, please provide the name of the government entity issuing the order:
______________________________________________________________________________________________
Order Date: ___________________________
• If requesting leave for a HEALTH CARE PROVIDER QUARANTINE OR ISOLATION ORDER/ADVICE, identify the health
care provider making the ordered or so advising:
_______________________________________________________________
_______________________________
Address: ____________________________________________________ City: ____________State: ___________
Order/Advice Date: __________________________
• I
f requesting leave for COVID-19 SYMPTOMS AND SEEKING DIAGNOSIS identify the health care provider or clinic
providing testing or other diagnostic services:
____________________________________________________________________________________________
_
Address: ___________________________________________________ City: _______________ State: _____
__
Order/Advice Date: __________________________
• If
requesting leave to CARE FOR AN INDIVIDUAL SUBJECT TO QUARANTINE/ISOLATION ORDER OR ADVICE provide
the name of the government entity or health care provider issuing the order/advice:
____________________________________________________________________________________________
_
Order Date: _________________________
__
State the Name of the Individual for whom you are providing care: _______________________________________
State the individual’s relationship to you: ___________________________________________________________
• If requesting leave for Child(ren)’s School/Childcare Closure/Unavailability provide the name(s) of the child(ren)
being cared for:
____________________________________________________________________________________
___
Identify the school, place of care or child care provider closed/unavailable: _______________________________
D
o you certify that no other suitable person is available to care for the child(ren) during the requested leave?
☐ YES ☐ NO
• I
f requesting leave for SELF-ISOLATION DUE TO CONCERN ABOUT EXPOSURE, has a health care provider advised you
to isolate for your safety or that of someone in your household? ☐ YES ☐ NO
If YES, identify the health care provider making the ordered or so advising: _______________________________
_
Address: ____________________________________________________ City: ______________ State: ________
Order/Advice Date: __________________________
Page 4 of 4
EPSL AND E-FMLA FORM REVISED 04/09/2020
SECTION VI:
1. The County must approve my request, and I may be required to meet eligibility requirements and/or submit
certification or supporting documentation to be eligible for Emergency Paid Sick Leave and Emergency Family
Medical Leave Act (E-FMLA)
.
2. Any leave of absence may be revoked by the Director of Human Resources upon written request of the Department
Head supported by evidence that the reason for granting leave was misrepresented or has ceased to exist.
3. I am responsible to pay my share of the premiums to maintain my health benefits coverage and other deductions.
4. My share of health premiums will be paid through payroll deduction whenever I utilize leave accruals to cover the
cost of premiums. If I do not have enough hours for the health deduction through payroll, I must arrange payment
with the Benefits Unit.
5. If I receive wage-replacement benefits (e.g. SDI, PFL, or Unemployment Benefits related to COVID -19), I may elec
t
t
o use applicable leaves balances as allowed by policy/MOU/state/federal law in situations where use of accrued
leave is not required.
6. I must notify my employer if I receive wage-replacement benefit (SDI, PFL, or Unemployment Benefits related to
COVID -19) and understand that I will be responsible for reimbursing the County for monies paid that result in an
overpayment.
I have read and understand the above information. I acknowledge that it is my responsibility to communicate with my
supervisor regarding my leave status. I understand that if my circumstances change, I must immediately info
rm my
supervisor and coordinate my return to work.
I have attached the supporting documentation to support this request: ☐ Yes ☐ No
Exclusion: Some health care workers and first responders may be excluded from FFCRA provisions which include Emergency
Paid Sick and E-FMLA. Human Resources is working closely with Department Heads to provide guidance as needed.
I UNDERSTAND THAT LEAVE TAKEN AS A RESULT OF THE COVID-19 PUBLIC HEALTH CRISIS FOR WHICH I RECEIVE PAID
LEAVE UNDER THE FFCRA WILL BE COUNTED AGAINST FMLA LEAVE ENTITLEMENTS. I ALSO UNDERSTAND THAT
PROVIDING FALSE OR MISLEADING INFORMATION ABOUT MY ABSENCE WILL RESULT IN DISCIPLINARY ACTION, UP TO
AND INCLUDING TERMINATION OF MY EMPLOYMENT.
______________________________________ ____________________________
Employee’s Signature Date
Leave Request Approved Recommend Denial Reason for Recommending Denial: _________________________________
*If the department finds an employee to be ineligible and recommends denial, the department is required to obtain concurrence from
Human Resources before notifying the employee.
Signature-Appointing Authority or Designee:
Date
FOR HUMAN RESOURCES DIVISION USE ONLY
Eligible for protected leave insurance coverage from _____________ to _____________ Protected Leave Ends: ________________
( ) Leave approved as recommended ( ) other: ______________________________ Dates: _________________________
_____________________________________________________________ _____________________________________________________________
Authorized Signature Date
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Request For EPSL And EFMLA Revised 4 9-2020

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Completed 18 July 2020

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