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