Fillable form and submit to HR at leavesofabsence@columbus.k12.oh.us at

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form and submit to HR at leavesofabsence@columbus.k12.oh.us at

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Emergency FMLA Employee Request Form
To reques
t leave on the basis of the Family First Coronavirus Response Act
(FFCRA) -
F
MLA,
please
complete the following request
form and submit to HR at leavesofabsence@columbus.k12.oh.us at least 30
days prior to leave (unless leave is unforeseen, in which case submit the form as soon as practical).
Employee Name: _________________________ Employee ID Number: _______________
Manager: _______________________________ Job Title: ________________________
Requested Leave Start Date: ________________ Estimated Return to Work Date: _________________
The reason for this FFCRA - FMLA leave request is (select the most appropriate box):
Time off work is expected to be (select the most appropriate box):
❏ For a c
ontinuous block of time (several continuous days, weeks or months off work).
❏ For a reduced work schedule (change in work schedule needed—fewer hours per day or fewer
hours per week).
❏ On an intermittent basis (periodic time off that is not usually expected to be the same days or
time off from week to week; examples may be intermittent child care availability).
Additional information about employee FMLA rights
and responsibilities will be provided to you in writing
within five business days after receipt of this notice (unless already provided).
Determination of eligibility for leave under the FFCRA, and/or additional documentation or clarification of
documentation, may be required prior to making a final FFCRA FMLA determination to approve or deny
an FMLA leave request. Please contact Human Resourc
es with any questions at
leavesofabsence@columbus.k12.oh.us.
Employee Signature: _____________________________________ Date: _______
For Human Resources Administration Use Only:
Paid Leave:
Approved
Denied
Date_____________
Signature_____________________
Waiting period dates: ___________ through ___________
Pay dates: ___________ through ___________
❏ You have become ill from COVID-19
❏ You are caring for a family member who has COVID-19
❏ You must care for a minor child because of a COVID-19 related school or daycare closure and are
unable to work from home
click to sign
signature
click to edit
click to sign
signature
click to edit
Emergency Paid Sick Leave Employee Statement
Please provide a brief description as to why you are requesting Emergency Paid Sick Leave:
Physician’s Name: _____________________________________________________________
Physician’s Phone Number: ______________________________________________________
Physician’s Address: ____________________________________________________________
---or---
Childcare Provider: ______________________________________________________________
Childcare Provider’s Phone Number: ________________________________________________
Childcare Provider’s Address: _____________________________________________________
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form and submit to HR at leavesofabsence@columbus.k12.oh.us at

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Completed 19 January 2021

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