COVID-19 Vaccination Leave Request Form
Vaccination is key to the resolution of the COVID-19 global pandemic. While County employees are not required to be
vaccinated, we strongly encourage you take the opportunity to protect yourselves as well as our community.
Employees will be provided paid time should their vaccination appointment fall during scheduled work time. Tompkins
County will provide up to 4 hours of paid leave for employees to receive each dose of the COVID-19 vaccine, for a total
of 8 hours maximum. This time includes travel to and from the distribution site. Employees who undergo vaccinations
outside their regular work schedule do so on their own time.
Employees must obtain approval from their supervisor to take the time from work and then submit documentation to
Human Resources from the immunization site with the proof of one or both vaccine appointments.
While the vaccine is free, insurance will be charged an administration fee. There is no copay, the cost is not subject to
deductible and there is no charge if you do not have health insurance.
As the vaccination process continues, please remain vigilant and continue to adhere to the public health guidelines put in
place to protect our community. In addition to vaccination, the Centers for Disease Control and Prevention recommends
continued use of preventive measures, including face coverings, physical distancing, avoiding close contact with people
who are sick, avoiding crowds and frequent hand washing, as the best defense against contracting and spreading the virus.
EMPLOYEE: Submit timely, complete, and sufficient medical documentation with this form to support your request for
paid time for Covid-19 Vaccination(s). Failure to provide a complete and sufficient medical documentation with this form
may result in a delay or denial of your requested paid leave. In order for this benefit to be processed, this claim form must
be received by Human Resources no later than Monday, 9:30 AM following the end of the pay period. After HR
approval, employee will be instructed to use "Covid Vaccine" under the Time Off column in WFR.
Employee Last Name: First: Middle Initial:
Telephone # (work):
Employee I.D. #.:
(If known)
Date of Vaccine #1:
Time of appointment:
Total time requested (with travel):
Date of Vaccine #2:
Time of appointment:
Total time requested (with travel):
By signing below, I verify that the information provided is true, complete and accurate to the best of my knowledge.
Employee Signature:
Supervisor Signature:
Supervisor Print Name:
** This form must be forwarded ASAP to: Sherry Murray, Employee Leave Associate HR Dept.**