Revised on July 20, 2020
Families First Coronavirus Response Act (FFCRA)
Emergency Paid Sick Leave (EPSL) and Emergency Family & Medical Leave (EFML)
Request Form
Employee Name: ___________________________________Employee ID# ___________
________ Date: _____________________
Department: ______________________________________ Supervisor: ___________
_____________________________________
I am requesting up to 80 hours (two weeks) of Emergency Paid Sick Leave (EPSL) for one of the following reasons:
I am unable to work because I am quarantined (pursuant to federal/state/local government order or advice of a healthcare
provider) and/or I am experiencing COVID-19 symptoms and seeking medical diagnosis. Email C19Resource@utdallas.edu first!
I am unable to work because of the need to care for an individual subject to quarantine (pursuant to federal, state, or local
government order or advice of a healthcare provider).
I am unable t
o work because of the need to care for my child(ren) who is under 18 years of age and whose school/child care
provider is closed or unavailable for reasons related to COVID-19.
I have been employed for at least 30 days with The University of Texas at Dallas and I am requesting up to 400 hours (ten weeks)
of Emergency Family & Medical Leave (EFML) for the following reason:
I am unable to work due to a bona fide need for leave to care for my child(ren) who is under 18 years of age and whose
school/child care provider is closed or unavailable for reasons related to COVID-19. This leave option is considered part
of the Family & Medical Leave Act (FMLA) and will be counted against the twelve week allotment. The first two weeks
will be paid at full pay as defined under the Emergency Paid Sick Leave (EPSL). The remaining ten weeks are paid at 2/3
of the regular rate of pay as defined under the Emergency Family & Medical Leave (EFML).
Family Member Information (related to your leave):
Name of Individual(s): __________________________________ Relationship: ____________________ Date(s) of Birth: __________
School Name: _________________________________________ City: _________________________________________________
I request permission to be absent continuously or
intermittently (check box) from ____________________ through ___________________.
Please read all applicable policy information related to the Families First Coronavirus Response Act (FFCRA) before signing below.
I acknowledge and understand the above information and all other information conveyed to me pertaining to the FFCRA including
Emergency Paid Sick Leave and Emergency Family & Medical Leave. The information I have provided is TRUE and COMPLETE. Any
MISLEADING or FALSE information provided by me may result in sufficient cause for denial of leave and/or disciplinary action. I
hereby grant permission for UT Dallas to verify information furnished by me regarding EPSL and EFML. I acknowledge I have READ
and UNDERSTOOD the information provided to me regarding UTD’s implementation of the FFCRA and I agree to comply with the
rules and regulations outlined therein.
Employee Signature: _____________________________________________ Date: ________________________________________
Supervisor Signature: ____________________________________________ Date: ________________________________________
As of 4/1/2020 - UTD Response to New Federal Emergency Paid Sick Leave and Emergency Family & Medical Leave
These provisions are subject to change based on forthcoming regulations from the Department of Labor, issued guidance, or other legal authority.
Note: Acceptable documentation supporting the need and eligibility for both EPSL or EFML is required for approval.
EPSL hours must be used continuously for COVID-19 related reasons other than childcare (1st and 2nd options below).
EPSL hours may be used in one day increments for unavailable childcare reasons related to COVID-19 (3rd option below).
EFML hours may be used in one hour increments for unavailable childcare reasons related to COVID-19 (4th option below).
Revised on July 20, 2020
Employees Applying for EPSL or EFML:
Employees who wish to apply for Emergency Paid Sick Leave (EPSL) and/or Emergency Family & Medical Leave (EFML)
must submit a complete and accurate FFCRA Request Form, along with acceptable supporting documentation, to the
Leave Administration Manager in the Office of Human Resources via email at LOA@utdallas.edu.
Below are examples of acceptable supporting documentation:
A medical statement provided by a health care provider or an order from the Department of Health and Human
Services/local
health agency that instructs the employee to self-quarantine due to COVID-19.
A written statement provided by the employee and/or the medical provider that the employee is experiencing
COVID-19 symptoms and is seeking a medical diagnosis.
A written statement provided by the employee that he/she is caring for an individual subject to an order to self-
quarantine pursuant to federal, state, or local government order or advice of a healthcare provider.
A written statement from the employee that he/she is caring for his/her child(ren) whose school/childcare
provider is closed or unavailable for reasons related to COVID-19. Documentation of school/childcare provider
closure or unavailability must be included with request.
Overview of Process:
1) Once the leave request is received/reviewed/approved, the employee and the department will receive email
notification from the Leave Administrator Manager. Also, Payroll will be notified to include a new Time Reporting Code
(TRC) on the employee's online Galaxy timesheet.
2) Payroll will notify the employee and the department once this process has been completed. Also, instructions on how
to report any approved leave on the employee’s online Galaxy timesheet will be provided.
Note: Please allow two weeks from the time the form is submitted for the entire process to be completed.
Additional Information:
Poster - Employees Rights Under FFCRA
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