SICK LEAVE ADVANCE – Employee Request and Agreement (COVID-19)
Job Classification: Department:
Due to the COVID-19, I request a Sick Leave Advance (not to exceed 75, 80 or 96 hours, depending on regular
schedule) to cover my leave from:
Start Date: ________________________ End Date: ________________________
Number of hours requested: _____________
At its discretion, the Department may determine the type and how many leave hours to advance, which will be
prorated for employees who do not work a full-time schedule.
I am requesting leave for the following circumstance related to COVID-19:
___ To care for myself
___ To care for a member of my family as defined by the applicable labor agreement
___ To provide childcare due to school closure from COVID-19
I have read and understand the SICK LEAVE ADVANCE PROCEDURE. I understand that any sick leave
advanced is a loan of time not yet earned that I am required to repay by forgoing accruing sick leave as it is
earned, until such time as I have repaid the entire amount advanced. I further understand that as a
condition of receiving a leave advance, I agree that if I separate from employment before fully repaying the
leave advance, I will repay the remaining unpaid balance, if any:
• at the time of separation; I hereby voluntarily agree and authorize the City to deduct any
remaining balance due from my final pay or other compensation due to me at separation, and
• if the amount due to me upon separation does not fully repay the remaining unpaid
balance, I agree to repay the full remaining amount directly within 60 days of receipt of a
demand for repayment.
Should I fail to repay any sick Leave advanced to me when due, I understand and agree that the City
will take appropriate action to collect on the unpaid balance, which may subject me to additional
costs and interest as allowed by law.
Signature: Date:
Return this completed from with your Request for Leave and Leave Protections form to your supervisor,
manager, or department’s Single Point of Contact (SPOC).
Department SPOC/Designee: Approved (Accrued Leave Exhausted) Disapprove (Leave Balances)
Name: ____________________________________ Signature: _____________________________ Date: _________
Human Resources Director/Designee: Approved (Accrued Leave Exhausted) Disapprove (Leave Balances)
Name: ____________________________________ Signature: _____________________________ Date:__________
Place Official Employee Personnel Folder
