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Emergency Childcare Leave Request
This form has been modified since it was saved. Please review all fields before submitting.
First Name
*
Last Name
*
Employee ID
*
Email
*
Department (not division)
*
Position
*
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.
*
True
No other person will be providing care for my child during the period for which I am requesting Emergency Childcare Leave.
*
True
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.
*
I understand
I understand that FFCRA expired on December 31, 2020 and that I am no longer eligible to receive partially paid FMLA
*
I understand
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.
*
I understand
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.
*
I understand
Please enter the name, DOB and ages of the child(ren) you are caring for.
Childs #1 Full Name
*
DOB
*
DOB
Age
*
School/Childcare Provider & Providers Contact Number for Child #1
*
Child #2 Full Name
DOB
DOB
Age
School/Childcare Provider & Providers Contact Number for Child #2
Child #3 Full Name
DOB
DOB
Age
School/Childcare Provider & Providers Contact Number for Child #3
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.
Beginning Date
*
Beginning Date
Ending Date
*
Ending Date
I elect to use my PML, PPL or Comp Time to provide income during this time.
*
Yes
I attest the above statements are true.
*
Yes
First Name
Last Name
Todays Date
Todays Date
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