Request for Emergency Paid Sick Leave
To request emergency paid sick leave as provided under the Families First Coronavirus Response
Act and the Educational Service Center of Central Ohio’s Emergency Paid Sick Leave Policy,
please complete the following request form and submit to your manager 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): ________________________________________________
Department: ________________________
Manager: ___________________________
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
Manager Signature Date
HR Department Rep. Signature Date ______
click to sign
signature
click to edit
In order to process your request, we will need supporting documentation.
The documentation requirement is listed below and corresponds to the reason you selected on
the first page:
1) The federal, state, or local quarantine or isolation order related to COVID-19
2)
The Health Care Provider’s contact information such as Name, Address, and Telephone
Number.
3)
The Health Care Provider’s contact information such as Name, Address, and Telephone
Number.
4)
The name and contact information for the individual you are caring for and their health
care provider’s contact information such as Name, Address, and Telephone Number.
5)
Your child’s name and contact information of their school or childcare provider that is
unavailable due to COVID-19 precautions.
6)
The Health Care Provider’s contact information such as Name, Address, and Telephone
Number.
For leave reasons (1), (2), or (3): employees taking leave shall be paid at either their regular rate
or the applicable minimum wage, whichever is higher, up to $511 per day and $5,110 in the
aggregate (over a 2-week period).
For leave reasons (4) or (6): employees taking leave shall be paid at 2/3 their regular rate or 2/3
the applicable minimum wage, whichever is higher, up to $200 per day and $2,000 in the aggregate
(over a 2-week period).
For leave reason (5): employees taking leave shall be paid at 2/3 their regular rate or 2/3 the
applicable minimum wage, whichever is higher, up to $200 per day and $12,000 in the aggregate
(over a 12-week period—two weeks of paid sick leave followed by up to 10 weeks of paid expanded
family and medical leave).
If you are requesting leave for reason 4, 5 or 6, please indicate if you wish to use your own accrued
time off to supplement the 1/3 that you will not be paid.
Yes, I wish to use my accrued time off to supplement the 1/3 rate that will be unpaid.
No, I wish to be docked for the 1/3 rate that will be unpaid.
If you have any questions, please email Leavesofabsences@escco.org
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