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Emergency Childcare Leave Request

  1. 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. *
  2. No other person will be providing care for my child during the period for which I am requesting Emergency Childcare Leave. *
  3. 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. *
  4. I understand that FFCRA expired on December 31, 2020 and that I am no longer eligible to receive partially paid FMLA*
  5. 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. *
  6. 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. *
  7. Please enter the name, DOB and ages of the child(ren) you are caring for.
  8. 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.
  9. I elect to use my PML, PPL or Comp Time to provide income during this time.*
  10. I attest the above statements are true.*
  11. Leave This Blank: