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. Reason for requesting leave ( check the one box which applies)*

    *Before selecting the last option please consult with Human Resources.

    1. I am quarantined pursuant to Federal, State, or local government order related to COVID19.
    2. I have been advised by a health care provider to self-quarantine related to COVID19.
    3. I am experiencing COVID19 symptoms and seeking a medical diagnosis.
    4. I have a bona fide need to care for an individual subject to quarantine for reasons related to COVID19.
    5. 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.
12. Amount of Leave Requested: Based on the attached supporting medical documentation, I am requesting that leave be granted for the following period of time.

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

16. Beginning Date*
    Beginning Date

17. Ending Date*
    Ending Date

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

    1. Yes

21. First Name

22. Last Name

23. Todays Date
    Todays Date

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