Fillable STATE OF ARIZONA Families First Coronavirus Response Act, (Arizona)

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STATE OF ARIZONA Families First Coronavirus Response Act, (Arizona)

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1
Families First Coronavirus Response Act 2020
Notice
of Emergency Family and Medical Leave Act Designation
April 30, 2020
STATE OF ARIZONA
Families First Coronavirus Response Act, Effective 04/01/20 - 12/31/20
Notice of Emergency Family and Medical Leave Expansion Act
Designation
Leave covered under the Family and Medical Leave Act (FMLA) must be designated as FMLA-protected
and the employer must inform the employee of the amount of leave that will be counted against the
employee’s FMLA leave entitlement. In order to determine whether leave is covered under the FMLA, the
employer may request that the leave be supported by a certification. If the certification is incomplete or
insufficient, the employer must state in writing what additional information is necessary to make the
certification complete and sufficient.
To: ________________
_______________________
Date: ___________
__________________________
We have reviewed your request for leave under the FMLA and any supporting documentation
that you have provided. We received your most recent information on __________ and decided:
_____ Your FMLA leave request is approved. All leave taken for the purpose of caring for
your child/ren due to school closure or childcare or provider unavailability due to the
public health emergency related to COVID-19/Coronavirus will be designated as FMLA
leave.
The FMLA requires that you notify us as soon as practicable if dates of scheduled leave
change or are extended, or were initially unknown. Based on the information you have
provided to date, we are providing the following information about the amount of time
that will be counted against your FMLA leave entitlement.
Your FMLA leave is approved from _______________ to ________________.
(If end date is
unknown, write unknown)
_____ Provided there is no deviation from your anticipated leave schedule, the following
number of hours, days, or weeks will be counted against your FMLA leave entitlement:
____________________________________________________________________________
_____ Because the leave you will need will be unscheduled, it is not possible to provide the
hours, days, or weeks that will be counted against your FMLA entitlement at this time. You
have the right to request this information once in a 30-day period (if leave was taken in the 30-
day period).
2
Families First Coronavirus Response Act 2020
Notice
of Emergency Family and Medical Leave Act Designation
April 30, 2020
_____ You will be granted _____ hours of Emergency Paid Sick Leave which may be used
concurrently with the unpaid portion of your FMLA Leave. This time will count against your
FMLA leave entitlement.
_____ During the time when you are paid 2/3 of your salary on FMLA leave, you ___ HAVE
_____ HAVE NOT requested to use your accrued paid leave balances for the unpaid 1/3 of
your wages. Any paid leave taken for this reason will count against your FMLA leave
entitlement. (If you change this designation, it will be effective the next pay period.)
Additional information may be needed to determine if your FMLA leave request can be
approved:
_____ The information you have provided is not complete and sufficient to determine whether
the FMLA applies to your leave request. You must provide the following information no later
than ______________________________, (Provide at least seven calendar days) unless it
is not practicable under the particular circumstances despite your diligent good faith efforts,
or your leave may be denied. The information needed is (specify):
____________________________________________________________________________
_____ Your FMLA Leave request is Not Approved because:
_____ The FM
LA does not apply to your leave request.
_____ You have ex
hausted your 12-week FMLA leave entitlement in the applicable 12-
month period.
_____ You work in a position that has been designated as a health care provider
or emergency responder, and as such, you are excluded from this provision of the
FMLA.
_____ You have requested to use Emergency Paid Sick Leave from ___________ to
___________. Please work with your supervisor to reflect the correct pay codes on your
timesheet.
Any q
uestions may be directed to your Human Resources representative.
____________________________________________________________________________________
It is mandatory for employers to inform employees in writing whether leave requested under the FMLA
has been determined to be covered under the FMLA. 29 U.S.C. § 2617; 29 C.F.R. §§ 825.300(d), (e). It is
mandatory for employers to retain a copy of this disclosure in their records for three years. 29 U.S.C. §
2616; 29 C.F.R. § 825.500.
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STATE OF ARIZONA Families First Coronavirus Response Act, (Arizona)

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Completed 12 August 2020

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