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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. *
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