Request for Leave under the Families First Coronavirus Response Act (FFCRA)
Effective April 1, 2020 December 31, 2020
Name: _____________________________
Department: ________________________
Estimated Start Date of Leave: __________
Phone: __________________________
Hire Date: ________________________
Estimated End Date of Leave: ________
Emergency Paid Sick Leave Act (COVID-Sick) Leave The FFCRA provides up to 80 hours (10 workdays)/112 hours for sworn
Fire shift employees) of emergency paid sick leave to full-time employees who are unable to work, either onsite or remotely,
due to COVID-19, and for specific reasons listed below. Part-time employees are entitled to emergency paid sick leave based
on the number of hours the employee works, on average, over a two-week period. The Department of Labor (DOL) provided
additional guidance related to determining the appropriate number of hours if a part-time employee’s schedule is unknown
or varies. There are requirements for necessary information for employees who make such requests for this emergency paid
sick leave (COVID-Sick). See below for those requirements. Note: Employees do not get a new 80 hours for each reason.
I am unable to work due to the following reason:
Check the applicable box:
1. I am subject to a federal, state, or local quarantine or isolation order related to COVID-19, per a public
health authority; specify the name of the government entity that issued this order:
____________________________________________. Number of hours requested: ______
2. I have been advised by a health care provider to self-quarantine due to concerns related to COVID-
19; name of health care provider who provided such advice: ______________________________.
Number of hours requested: _______
3. I am experiencing COVID-19 symptoms and am seeking a medical diagnosis. Number of hours requested:
4. I am caring for an individual subject to an order described in 1) above or 2) self-quarantined as
described in 2) above; name of government entity ____________________ or name of health care
provider: _____________________________. Number of hours requested: _________
5. I am caring for a child whose school or place of care is closed, or the childcare provider is
unavailable for reasons related to COVID-19; name of child _____________________; name of
school, childcare provider which is closed: ____________________. I certify that no other
suitable person is available to care for my child. Number of hours requested: _________. Please
note that this leave will be charged against your expanded FMLA leave balance if you are
eligible for expanded FMLA leave (worked at least 30 days for the City).
6. I am experiencing any other substantially-similar condition specified by the Secretary of Health and
Human Services. Number of hours requested: _________
Emergency Family and Medical Leave Expansion Act (Expanded FMLAFMLA-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
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
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
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,
click to sign
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For Timekeeper Use Only
Expanded FMLA Calculation (if the 2/3 amount applies) /Approval:
Period End Date
Total COVID-19 EFMLA hours
Other Paid Leave Hours Requested
to be Applied (COVID-Sick, Sick,
Vacation, Compensatory Time)*
*Specify how many hours of each type of paid leave, identifying the paid leave category
Paid Sick Leave Calculation (Timekeeper):_______________________________________________Date:_______________
For Human Resources Use Only
Hire Date: Status/hours work per week:
Documentation provided (Y/N): Hourly Rate of Pay: _____________________________________
Current Available FMLA Leave Balance: ____________
HR Generalist/Liaison Approval: ________________________________________________Date:_______________
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