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FAMILY FIRST CORONAVIRUS RESPONSE ACT (FFCRA)-EMERGENCY PAID SICK LEAVE (EPSL) REQUEST
This form has been modified since it was saved. Please review all fields before submitting.
First Name
*
Last Name
*
Employee ID
*
Email
*
Department (not division)
*
Position
*
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.
Beginning Date
*
Beginning Date
Ending Date
*
Ending Date
I acknowledge that the information submitted is true and accurate.
*
Yes
First Name
Last Name
Todays Date
Todays Date
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