Fillable Request for Leave under the Families First Coronavirus (Montgomery Schools)

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Request for Leave under the Families First Coronavirus (Montgomery Schools)

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Request for Leave under the Families First Coronavirus Response Act
(Requires ERSC Authorization)
Employee and Retiree Service Center (ERSC)
MONTGOMERY COUNTY PUBLIC SCHOOLS • Rockville, Maryland 20855
MCPS Form 430-1C
April 2020
INSTRUCTIONS:
See reverse side for detailed information.
Name ________________________________________
Last First MI Employee No.
Number of Days (or) Hours Expected Dates of Leave / / through / /
School/Location Name
Job Title ______________________________________________________________________ Phone(s) - - , - -
CHECK TYPE OF LEAVE □ COVID-19 Sick Leave □ COVID-19 Family Leave
Attach completed MCPS form 440-35, Certification of Physician or Health Care Provider.
Specify details as appropriate ____________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
I understand that my electronic submission of this form and my electronic signature are intended to be, constitute, and are equivalent to my personal signature.
Read reverse side carefully before signing: _______________________________________________________________________________ _____/_____/______
Signature, Employee Date
AUTHORIZATION
□ Request Reviewed Substitute Required? □ Yes □ No □ Comments ___________________________________________________________________
I understand that my electronic submission of this form and my electronic signature are intended to be, constitute, and are equivalent to my personal signature.
_____/_____/______
Signature, Principal/Director/Supervisor Date
□ Approved □ Not Approved (give reason)
I understand that my electronic submission of this form and my electronic signature are intended to be, constitute, and are equivalent to my personal signature.
_____/_____/______
Signature, ERSC Approver Date
CLEAR FORM
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Beginning April 1, 2020, and through December 31, 2020, additional leave may be available to employees under the Families First
Coronavirus Response Act (the Act). The Act provides eligible employees with paid short-term sick leave (which, we will call “COVID Sick
Leave”) and/or paid emergency family leave (“COVID Family Leave”) if they cannot work or telework in certain circumstances. Specifically:
Emergency paid leave now offered under the Families First Coronavirus Response Act
Two Types:
COVID Sick Leave—up to 80 hours (10 days) at either full pay or two-thirds pay depending on the situation
COVID Family Leave—up to 10 weeks at two-thirds pay
Qualifying Reasons for COVID Sick Leave and/or COVID Family Leave
An employee is entitled to take leave related to COVID-19 if the employee is unable to work, including unable to telework, for the following
reasons:
1. is subject to a Federal, State, or local quarantine or isolation order related to COVID-19 (COVID Sick Leave eligible at full pay for up to
10 days);
2. has been advised by a health care provider to self-quarantine related to COVID-19 (COVID Sick Leave eligible at full pay for up to 10
days);
3. is experiencing COVID-19 symptoms and is seeking a medical diagnosis (COVID Sick Leave eligible at full pay for up to 10 days);
4. is caring for an individual subject to an order described in (1) or self-quarantine as described in (2) (COVID Sick Leave eligible at two-
thirds pay for up to 10 days)
5. is caring for his or her child whose school or place of care is closed (or child care provider is unavailable) due to COVID-19 related
reasons (COVID Family Leave for up to 12 weeks at two-thirds pay); or
6. is experiencing any other substantially-similar condition specified by the U.S. Department of Health and Human Services (COVID Sick
Leave eligible at two-thirds pay for up to 10 days).
Additional information can be found by accessing the Coronavirus FAQ’s link on the Employee and Retiree Service Center web page.
Employees who have already used Family and Medical Leave Act (FMLA) protected leave in the last 12 months are not eligible for additional
COVID Family Leave. They will only be eligible for COVID Sick Leave.
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Request for Leave under the Families First Coronavirus (Montgomery Schools)

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Completed 10 February 2021

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