Request for Leave Due to COVID-19
Return'completed'from'to'LOA-COVID19-group@pcc.edu' ' ' ' 'Revised'3.31.20'
PCC'Employees'may'be'eligible'for'paid'leave'due'to'COVID-19'related'emergency'leave'and'sick'leave'
provisions.''Please'complete'the'attached'form'and'return'to'the'benefits'office,'LOA-COVID19-group@pcc.edu.
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I'am'unable'to'work'or'telework'for'the'following'reason:'
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I'am'ordered'by'a'federal,'state'or'local'order'to'quarantine'or'self-isolate'related'to'COVID-19
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I'have'been'advised'to'self-quarantined'by'my'healthcare'provider
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I'am'experiencing'symptoms'of'COVID-19'and'am'seeking'diagnosis'or'treatment
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I'am'caring'for'an'individual'who'is'ordered'to'quarantine'or'self-isolate'or'who'is'advised'to'
self-quarantined'by'a'healthcare'provider
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I'am'caring'for'my'child'whose'school'or'daycar e'has'closed,'or'whose'child'care'provider'is'unavailable'
due'to'COVID-19
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I'am'unable'to'work'to'car e'for'a'substantially'similar'co ndition'as'determined'by'the''
secretary'of'health'and'human'services
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I'am'unable'to'telecommute'(because'telecommuting'work'is'not'available)
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Employees'may'be'eligible'for'one'or'more'of'the'following'leaves:'
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!"#$%#&'()*+,-).,'/)0#+1#)2!3*.04'–'Up'to'80'hours'of'paid'leave'for'the'following'reasons:''(1)'the'employee'is'ordered'to'
quarantine'or'self-isolate'related'to'COVID-19;'(2)'advised'to'self-quarantined'by'their'healthcare'provider;'(3)'experiencing'
symptoms'of'COVID-19'and'seeking'diagnosis'or'treatment;'(4)'caring'for'an'individual'who'is'ordered'to'quarantine'or'self-isolate'
or'who'is'advised'to'self-quarantined'by'a'healthcare'provider;'(5)'caring'for'their'child'whose'school'or'daycare'has'closed,'or'
whose'child'care'provider'is'unavailable'due'to'COVID-19;'or'(6)'unable'to'work'to'care'for'a'substantially'similar'condition'as'
determined'by'the'secretary'of'h ealth'and'human'services.'Leave'for'reasons'(1)'-'(3)'is'at'the'regular'pay'rate,'capped'at'$511' per'
day'and'a'total'of'$5,110.''Leave'for'reasons' (4)'-'(6)')'is'at'2/3'regular'pay'rate,'capped'at'$200'per'day'and'a'total'of'$2,000.
!"#$%#&'()5+",6()7#-,'+6)0#+1#)2!357084'–'Employees'may'be'eligible'for'up'to'12'weeks'of'leave'if'they'are'unable'to'
work/telework'to'care'for'their'child'because'their'school/daycare'is'close d'or'their'child'care'provider'is'unavailable'due'to'a'
COVID-19'declared'public'health'emergency. The'first'10'days'of'leave'is'unpaid'and'the'subsequent'10'weeks'is'paid'at'2/3'regular'
pay'rate,'capped'at'$200'per'day'and'a'tota l'of'$10,000.'''
Oregon Sick Leave – Allows'employees'who'were'schedule d'to'work'to'use'accrued'sick'leave'(up'to'a'ma ximum'of'80'hours)'for'
childcare'purposes'due 'to'school'closure s;'unable'to'telecommute'because'work'i s'not'available,'a'CO VID-19'related'absence;'to'care'
for'a'family'member'with'COVID'related'illness;'or'certain'public'health'emergencies'including'closure'of'the'employee’s'place'of'
business.
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Based'on'the'information'above'PCC'will'apply'applicable'leaves.''Please'see'PCC'COVID-19'FAQ'for'additional'
information.'
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I'request'to'utilize'my'other'appropriate'leave'accruals'before'going'into'leave'without'pay''
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Employee'Signature'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''Date'
Supervisor'Signature''''''''''''' '''''''''''''''''''''''''''' '''''''''''''''''''''' ''''''''''''''''''''''''''''''Date'
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