COVID-19 Request Form
Revised 03/31/2020
Instructions:
Employees requesting leave related to COVID-19 should complete this form if the leave is requested for one of the
reasons listed below. Requests for any other leave should be submitted pursuant to standard procedures. Return
this form by clicking “Submit” below or by email to
TotalRewards@wichita.edu. A Human Resources
Representative will respond by telephone to the contact listed below on the same University business day the
form is received, or within two (2) University business days during times of high-volume requests.
Do not r eport t o work if you have been d iagnosed with COVID-19, are exhibiting any symptoms of COVID-
19, or if you h ave been in direct contact with an individual with a confirmed case of COVID-19. Please visit
www.wichita.edu/COVID-19 for University updates.
Employee Details
Name: myWSU ID:
Mailing Address:
Email:
Have you contacted the
Sedgwick County Health
Department or your local
public health official?
Yes
No
Home/Cell Phone: Alt. Phone:
Supervisor: Department:
Request Details
Subject to quarantine or isolation order by Federal, State or local order related to COVID-19
Advised by health care provider to self-quarantine related to COVID-19
Experiencing COVID-19 symptoms and seeking medical diagnosis
Caring for an individual subject to a quarantine or self-isolation order related to COVID-19
Caring for a
dependent whose school or place of care is closed or unavailable for reasons related
to COVID-19
Requ
est due to voluntary disclosure of vulnerable health status
Other (specify):
I certify that the information contained on this form is true and correct to the best of my knowledge. I
authorize Wichita State University to obtain and verify any necessary information regarding my request. I
understand that providing false information may result in corrective action up to, and including, separation of
employment. I understand that I should still follow all department policies, including call-out procedures.
Employee Signature
Date
SUBMIT
PRINT
click to sign
signature
click to edit
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