Mississippi Delta Community College does not discriminate on the basis of age, race, color, national origin, religion, sex, sexual orientation, gender
identity or expression, physical or mental disability, pregnancy, or veteran status in its educational programs and activities or in its employment
practices. The following person has been designated to handle inquiries regarding the non-discrimination policies: Steven J. Jones, Vice President
of Administrative Services, Tanner Hall, Suite 202, P. O. Box 668, Moorhead, MS 38761, 662-246-6304; EEOC@msdelta.edu.
REQUEST FOR EMERGENCY PAID SICK LEAVE
To request emergency paid sick leave as provided under the Families First Coronavirus Response
Act and Mississippi Delta Community College’s Emergency Paid Sick Leave Policy, please
complete the following request form and submit to your Supervisor or the Human Resources
department as soon as possible before leave commences. Verbal notice will be accepted until a
form can be provided.
Employee Name (print clearly):
Employee ID#:
Department:
Supervisor:
Requested Leave Start Date: Estimated End Date:
The amount of emergency paid sick leave being requested is __________ hours.
The reason for this emergency paid sick leave request is (check the appropriate reason below):
❏ 1) I am subject to a federal, state, or local quarantine or isolation order related to COVID–19.
❏ 2) I have been advised by a health care provider to self-quarantine due to concerns related to
COVID–19.
❏ 3) I am experiencing symptoms of COVID–19 and seeking a medical diagnosis.
❏ 4) I am caring for an individual who is subject to either number 1 or 2 above.
❏ 5) I am caring for my child whose primary or secondary school or place of care has been closed, or
my childcare provider is unavailable due to COVID–19 precautions.
❏ 6) I am experiencing another substantially similar condition specified by the secretary of health
and human services.
Employee Signature Date
Supervisor Signature Date
Associate Vice-President/Vice-President Signature Date
Human Resources Director Signature Date
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