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

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