Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

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

  1. 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.

  2. Amount of Leave Requested:

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

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

  4. Leave This Blank: