Signed into law July 14, 2020, the Healthy Families Workplaces Act (HFWA) requires the State to provide eligible
employees with job-protected, public health emergency leave effective January 1, 2021 for specific reasons related to
the pandemic. During the entirety of a public health emergency (until four weeks after the public health emergency
ends), full-time employees who are unable to work or telework are eligible for up to eighty (80) hours of PHEL (regular
base pay).
This form should be used by employees to notify their supervisor the need for leave, but should not be considered as
requested documentation for PHEL. More information, including eligibility can be found at
Employee Name:_______________________________________________ Employee ID:______________________
Department:___________________________________________________ Phone:____________________________
Date(s) of Leave Requested: __________________________________ Number of Hours:________________
I was/will be absent due to the following reason:
Subject to an isolation order or asked to self-quarantine by a healthcare provider;
Ill with COVID-19-like symptoms;
Seeking or obtaining medical diagnosis, care or treatment, preventative care, or care of such illness;
Being unable to work due to a health condition that may increase susceptibility or risk of such illness;
Caring for a child whose school, child care provider is unavailable, closed, or providing remote instruction due
to the public health emergency; or
Closure of the temporary employee’s work location, and work cannot be performed remotely.
__________________________________________________ ___________________________
Employee Signature (electronic signature accepted) Date
Return completed form to your supervisor or department HR professional.
Received by Department:
Entered into TCP:
Healthy Families and Workplaces Act
Public Health Emergency Leave (PHEL) Notification
555 S. Howes Street, 2
Floor | Campus Delivery 6004
Fort Collins, CO 80523-6004
P: 970-491-6947 (MyHR) |
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