COVID 19 _Leave_Request_Form.pdf

Emergency Paid Sick Leave

☐ Check here if you want to submit a request for Emergency Paid Sick Leave.

Employee Name (Last, First, MI)

Primary Phone Number



I request leave beginning on (date):

My expected return date is:

Select one or more of the following reasons for why you are unable to work, including telework:

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I am subject to federal, state, or local quarantine or isolation order related to COVID–19.



Name of governmental entity ordering quarantine:

☐

I have been advised by a health care provider to self-quarantine due to concerns related to COVID–19.

Name of the health care professional advising self-quarantine:

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I am experiencing symptoms of COVID–19 and seeking a medical diagnosis.

Name of the health care professional and appointment date and time:

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I am caring for an individual who is subject to either number 1 or 2 above*.

Name and relationship to employee:

Name of governmental entity ordering quarantine or health care professional advising self-quarantine:

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I am caring for a minor son or daughter due to a school or place of closure, or the childcare provider for my son or

daughter is unavailable, due to COVID–19. I certify that no other suitable person is available to care for my son or

daughter during the period for which I am receiving paid leave.

Name and Age of Child:

Name of School / Place of Care that is Closed:

Name and Age of Child:

Name of School / Place of Care that is Closed:

Name and Age of Child:

Name of School / Place of Care that is Closed:

☐

I am experiencing any other substantially similar condition specified by the Secretary of Health and Human Services in

consultation with the Secretary of the Treasury and the Secretary of Labor.

COVID-19 LEAVE REQUEST FORM

Select "Fill a Copy"

Complete Form and select "Finalize"