FAMILY FIRST CORONAVIRUS RESPONSE ACT (FFCRA)-EMERGENCY PAID SICK LEAVE (EPSL) REQUEST

2. First Name*

3. Last Name*

4. Employee ID*

6. Email*

7. Department (not division)*

8. Position*

10. Vaccination Status
    Employees are considered fully vaccinated: • 2 weeks after their second dose in a 2-dose series, like the Pfizer or Moderna vaccines, or • 2 weeks after a single-dose vaccine, like Johnson & Johnson’s Janssen vaccine. If it has been less than 2 weeks since your shot, or if you still need to get your second dose, you are NOT fully vaccinated.

    Employees are considered fully vaccinated: • 2 weeks after their second dose in a 2-dose series, like the Pfizer or Moderna vaccines, or • 2 weeks after a single-dose vaccine, like Johnson & Johnson’s Janssen vaccine. If it has been less than 2 weeks since your shot, or if you still need to get your second dose, you are NOT fully vaccinated.

12. Are you fully vaccinated? See explanation above.*
    -- Select One --YesNo

14. Please attach a copy of your COVID-19 Vaccination Record if you are considered fully vaccinated.

16. Have you tested positive for COVID-19 within the past 3 months?*
    -- Select One --YesNo

18. Reason for requesting leave ( ONLY SELECT ONE)*
    -- Select One --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.

20. Amount of Leave Requested:
    Based on the attached supporting medical documentation, I am requesting that leave be granted for the following period of time.

    Based on the attached supporting medical documentation, I am requesting that leave be granted for the following period of time.

22. Please attach your supporting documentation. Requests will not be reviewed without documentation.

24. Beginning Date*
    Beginning Date

25. Ending Date*
    Ending Date

27. I acknowledge that the information submitted is true and accurate. *

    1. Yes

29. First Name

30. Last Name

31. Todays Date
    Todays Date

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