Fillable Request for Emergency Paid Sick Leave To request

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Request for Emergency Paid Sick Leave To request

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The Request for Emergency Paid Sick Leave To request form is 2 pages long and contains:

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  • 10 check-boxes
  • 18 other fields

Country of origin: OTHERS
File type: PDF

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Request for Emergency Paid Sick Leave
To request emergency paid sick leave as provided under the Families First Coronavirus Response
Act and Columbus City School’s Emergency Paid Sick Leave Policy, please complete the
following request form and submit to leavesofabsence@columbus.k12.oh.us as soon as possible
before leave begins. Verbal notice will be accepted until a form can be provided.
Employee Name:__________________________ Employee ID Number: _________________
Manager: _______________________________
Requested Leave Start Date: ________________ Estimated End Date: ____________
The amount of emergency paid sick leave being requested is __________ hours.
The reason for this emergency paid sick leave request is (check the appropriate reason below):
❏ 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 due to concerns related
to COVID–19.
❏ 3) I am experiencing symptoms of COVID–19 and seeking a medical diagnosis.
❏ 4) I am caring for an individual who is subject to either number 1 or 2 above.
❏ 5) I am caring for my child whose primary or secondary school or place of care has been
closed, or my childcare provider is unavailable due to COVID–19 precautions.
❏ 6) I am experiencing another substantially similar condition specified by the secretary
of health and human services.
Employee Signature Date
For Human Resources Administration Use Only:
For Payroll
Approved
Denied
Date_____________
______
Signature_____________________
# Of Approved Paid Hours _______________
Full pay rate
(own sickness)
I am requesting to work remotely, if my position allows it, in lieu of FFCRA leave.
I would like to use my personal leave to supplement FFCRA pay if my FFCRA pay is not at 100%
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Emergency Paid Sick Leave Employee Statement
Please provide a brief as to why you are requesting Emergency Paid Sick Leave:
Physician’s Name: _____________________________________________________________
Physician’s Phone Number: ______________________________________________________
Physician’s Address: ____________________________________________________________
---or---
Childcare Provider: ______________________________________________________________
Childcare Provider’s Phone Number: ________________________________________________
Childcare Provider’s Address: _____________________________________________________
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Request for Emergency Paid Sick Leave To request

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Completed 13 January 2021

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