Fillable State of Arizona Notification of Need for Leave (Arizona)

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State of Arizona Notification of Need for Leave (Arizona)

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The State of Arizona Notification of Need for Leave (Arizona) form is 3 pages long and contains:

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  • 4 check-boxes
  • 28 other fields

Country of origin: US
File type: PDF

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State of Arizona
Notification of Need for Leave for COVID-19 Reasons
NOTE: Please submit this form to your agency Human Resources office as soon as possible when you
become aware that you need one or both of these types of leave.
Employee Name: _____________________________________________ EIN:_________________
Employee Email Address (personal preferred): ___________________________________________
Date of Request: ______________________
I request leave from (Date): _____________________ through (Date): _________________
Leave is Requested for the Following Reason(s) (Check One or Both as applicable):
_____
Emergency Paid Sick Leave
of up to 80 hours maximum between April
1 and December 31, 2020 because I am unable to work or telework for any reason/s related to
COVID-19.
Check the box next to all reasons that apply to your request for Emergency Paid
Sick Leave:
(1) I am subject to a Federal, State, or local quarantine or isolation order related to COVID–19.
The name of the government entity that issued the quarantine or isolation order is:
___________________________________________________________________________.
(2) I have been advised by a health care provider to self-quarantine due to concerns related to
COVID–19. The name of the health care provider who advised me to self-quarantine for
COVID-19 related reasons is:________________________________________________.
(3) I am experiencing symptoms of COVID–19 and seeking a medical diagnosis or pending
testing. The name of the health care provider through whom I am seeking a diagnosis or
received a test is: _________________________________________________________.
(4) I am caring for an individual who is subject to quarantine under number 1 or 2 above.
The government entity that issued the quarantine or isolation order to which the individual is
subject is: _________________________; OR the name of the health care provider who
advised the individual to self-quarantine is: _____________________________; and the
relationship of the individual to me is: PARENT; SPOUSE; CHILD; ROOMMATE;
OTHER: _________________________________.
(5) I am caring for my son or daughter (including a foster child or stepchild) due to their school or
childcare facility or provider being closed or unavailable, due to COVID–19
precautions. Please provide the information requested below that relates to these child/ren.
Note: If you check this item, and you have been employed by the State for the
past 30 calendar days, please also check Emergency Family and Medical Leave
Expansion Act Leave on the following page.
Notification of Need for Leave for COVID-19 Reasons Page 1 of 3 Rev. 08/11/2020
To request this form in an alternate format, please call 602-542-5482 or email HumanResources@azdoa.gov
State of Arizona
Notification of Need for Leave for COVID-19 Reasons
_____ Emergency Family and Medical Leave Expansion Act Leave
I need leave to care for my child/ren because the school or place of care has
been closed, or the child care provider of my child/ren is unavailable, due to a public
health emergency relating to the Coronavirus (COVID-19). I have been employed
by the State of Arizona for at least 30 calendar days (i.e., I have been or will have
been a State employee the 30 calendar days immediately prior to the day my requested
leave is to begin).
If you checked Item 5 on Page 1, please provide the following information:
Name(s) of child/ren: _______________________________________________________
Name of the school, place(s) of care, or child care provider(s) that closed or became
unavailable due to COVID-19 reasons: ________________________________________
Is the school/childcare provider offering any in-person classes? ____ Yes ____ No
If yes, what is the schedule of in-person classes?
___________________________________________________________________________
Please initial:
____ I represent that no other suitable person is available to care for the child/ren
during the period of requested leave.
IMPORTANT: While on Emergency Paid Sick Leave to care for another individual, or while
caring for your child/ren because their school or care provider is closed or unavailable,
you are entitled to only 2/3s of your regular rate of pay, up to a maximum of $200 per day.
You may elect to use paid leave from your annual and sick leave balances to supplement the
remaining 1/3 of your regular pay. Please indicate whether you would like to supplement your pay
while on Emergency Paid Sick Leave with paid leave below.
Similarly, while on Emergency FMLA Expansion Leave to care for your child/ren
because their school or care provider is closed or unavailable, you are entitled to
only 2/3s of your regular rate of pay, up to a maximum of $200 per day. You may
elect to use paid leave from your annual and sick leave balances to supplement the
remaining 1/3 of your regular pay. Please indicate whether you would like to supplement
your pay while on Emergency FMLA Expansion Leave with paid leave on the next page.
Notification of Need for Leave for COVID-19 Reasons Page 2 of 3
Rev. 08/11/2020
To request this form in an alternate format, please call 602-542-5482 or email HumanResources@azdoa.gov
_____________________________________________
_________________________________
State of Arizona
Notification of Need for Leave for COVID-19 Reasons
If you elect to supplement your pay with paid leave balances, your leave balances will be
deducted in an amount necessary to bring your pay up to your normal earnings level,
but not greater.
____ I would like to supplement my pay with paid leave from my applicable balances
____ I DO NOT wish to supplement my pay with paid leave from my applicable balances
Note: If you need leave for the birth of a child, your own serious health condition, to care for a
family member who has a serious health condition or another qualifying reason under the
FMLA, please contact your HR Office or representative before submitting this form.
Employee Signature (Electronic Signature Accepted)
Signature Date
Notification of Need for Leave for COVID-19 Reasons Page 3 of 3
Rev. 08/11/2020
To request this form in an alternate format, please call 602-542-5482 or email HumanResources@azdoa.gov
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State of Arizona Notification of Need for Leave (Arizona)

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Completed 11 December 2020

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