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Emergency Family and Medical Leave Expansion Act (Expanded FMLA – FMLA-COVID) – The FFCRA temporarily updates
the Family and Medical Leave Act (FMLA) to provide employees with up to 12 weeks of job-protected leave if they are
unable to work, either onsite or remotely, as a result of their minor son’s or daughter’s school or child care services being
closed due to the public health emergency associated with COVID-19. Employees are eligible if they have been employed
for at least 30 days. The following information must be provided:
• Name of child/children being cared for: _________________________________________
• Number of expanded FMLA leave hours needed: __________________________________
• Name of school or child care provider/center closed or unavailable related to
COVID19:________________________________________________________
• I certify that no other suitable person is available to care for my child/children.
o Yes _______
o No _______
Once approved, the first two weeks (2) are unpaid; however, for those first 2 weeks, the employee may use emergency
paid sick leave – COVID-Sick) or other available leave balances (accrued vacation; accrued sick, compensatory time) to
cover this first 2-week period. After the initial two (2) week period, the employee is eligible to receive two-thirds (2/3)
of their full pay for the remaining ten (10) weeks, as needed (if the employee has not opted to utilize other forms of paid
leave, like vacation, sick, and compensatory time, to receive their regular rate of pay).
This Expanded FMLA provision does not apply to any other reason for leave under the FMLA.
Check All Applicable Boxes:
☐ I am requesting expanded FMLA leave due to 1) my inability to work, either onsite or remotely, and 2) my
minor child(ren) whose school or place of care is closed, or child care provider is not available due to COVID-
19 related reasons. My request is for ☐Intermittent Leave OR ☐Concurrent Leave
☐ I am requesting that my emergency paid sick leave (COVID-Sick) be utilized for the first 2 weeks of expanded
FMLA leave (FMLA-COVID).
☐ If I am out longer than 2 weeks on expanded FMLA leave, I choose to use available sick leave, vacation leave,
or compensatory time be applied so that I can be paid at my regular rate of pay. Otherwise, I understand
that I will receive two-thirds (2/3) of my regular rate of pay.
I, (please print full name) , certify that I am unable to work, either onsite or
remotely, due to the reason(s) checked above, and have provided the above-referenced required information (see 1
st
page re: required information).
Signed Date
Signature of Supervisor Who Received Oral Notification & Necessary Required Information:
_____________________________________________________ Date Received: __________________________
HR Generalist/HR Liaison Signature: _________________________ Date: _________________________________
For all expanded FMLA leaves (FMLA-COVID and COVID-19 Sick Childcare), a copy of both pages of this completed document must be
scanned to the FMLA Coordinator in Human Resources, or in Fire or Police. HR Generalists/Liaisons/Timekeepers must also be
copied on this form. For emergency paid sick leave for regular COVID_19 Sick only, the Timekeeper must also receive a copy,
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