Emergency Childcare Leave Request

2. First Name*

3. Last Name*

4. Employee ID*

6. Email*

7. Department (not division)*

8. Position*

12. I am unable to work, including by means of telework, due to a bona fide need to care for my child who is under 18 years of age whose school or child care provider is closed or unavailable for reasons related to COVID19. *

    1. True

14. No other person will be providing care for my child during the period for which I am requesting Emergency Childcare Leave. *

    1. True

16. I understand that I must provide a statement of Special Circumstances for any child 14 years of age or older requiring me to provide care during the day. *

    1. I understand

18. I understand that FFCRA expired on December 31, 2020 and that I am no longer eligible to receive partially paid FMLA*

    1. I understand

20. I understand that I must use available accrued leave (PML, PPL, Comp) or leave without pay during my approval for Emergency Childcare Leave. I understand that all accrued leave must be exhausted prior to utilizing leave without pay. *

    1. I understand

22. I understand that if my child is home, not because his or her school is closed, but because I have chosen for him/her to remain home, I am not entitled to Emergency Childcare Leave. Parents are not eligible to take Emergency Childcare Leave if the child’s school is open to him/her for in-person attendance. *

    1. I understand

26. Please enter the name, DOB and ages of the child(ren) you are caring for.

28. Childs #1 Full Name*

29. DOB*
    DOB

30. Age*

32. School/Childcare Provider & Providers Contact Number for Child #1*

34. Child #2 Full Name

35. DOB
    DOB

36. Age

38. School/Childcare Provider & Providers Contact Number for Child #2

40. Child #3 Full Name

41. DOB
    DOB

42. Age

44. School/Childcare Provider & Providers Contact Number for Child #3

48. Amount of Leave Requested – I am requesting leave for the following period of time. Emergency Childcare Leave will only be approved through March 21, 2021.

50. Beginning Date*
    Beginning Date

51. Ending Date*
    Ending Date

53. I elect to use my PML, PPL or Comp Time to provide income during this time.*

    1. Yes

55. I attest the above statements are true.*

    1. Yes

57. First Name

58. Last Name

59. Todays Date
    Todays Date

Leave This Blank:


61. Submit Submit and Print

* indicates a required field