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FAMILY FIRST CORONAVIRUS RESPONSE ACT (FFCRA)-EMERGENCY PAID SICK LEAVE (EPSL) REQUEST
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Department (not division)
Reason for requesting leave ( check the one box which applies)
*Before selecting the last option please consult with Human Resources.
I am quarantined pursuant to Federal, State, or local government order related to COVID19.
I have been advised by a health care provider to self-quarantine related to COVID19.
I am experiencing COVID19 symptoms and seeking a medical diagnosis.
I have a bona fide need to care for an individual subject to quarantine for reasons related to COVID19.
I am experiencing a substantially, similar condition as specified by the Secretary of Health and Human Services, in consultation with the Secretaries of Labor and Treasury.
Amount of Leave Requested: Based on the attached supporting medical documentation, I am requesting that leave be granted for the following period of time.
Please attach your supporting documentation. Requests will not be reviewed without documentation.
I acknowledge that the information submitted is true and accurate.
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