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

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

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

  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: