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.
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.
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
Leave This Blank:


33. Submit Submit and Print

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