Emergency Paid Sick Leave

Emergency Paid Sick Leave

Emergency Paid Sick Leave

FFCRA Emergency Paid Sick Leave (EPSLA) Application

Request Form

A. INSTRUCTIONS TO EMPLOYEE

The federal “Emergency Paid Sick Leave Act” (EPSLA) (a part of the “Family First Coronavirus Response Act”) provides employees with up to 80 hours of emergency paid sick leave (EPSL) for specified Coronavirus (COVID-19) related reasons (listed in section B below). If you believe you qualify for EPSL, please complete sections B, C (if applicable), D and E. Be as specific as you can. Your failure to provide the requested information may result in denial of your request. For some requests, you may be required to submit additional medical or other appropriate documentation.

B. QUALIFYING REASONS FOR EPSL

The chart below lists six qualifying reasons for EPSL. To qualify for EPSL, you must be unable to come to work or unable to work from home (telework) due to one of these reasons. Please check all applicable reasons you qualify for EPSL.

Use the file upload tp attach documentation required to support your request. If documentation is unavailable, you may provide the information requested and certify that such information is true and accurate by your signature at the end of this form. For medical documentation, please review the clarification at the end of this form.

Full-time employees are eligible for up to 80 hours of EPSL. Part-time employees may receive a prorated amount of EPSL , based on the prior 2-week average hours worked.

RATE OF SICK LEAVE PAID
for options 1, 2 & 3 is the following:
Hourly rate not to exceed $511 per day and $5,110 in total
1.
2.
3.
RATE OF SICK LEAVE PAID
for options 4, 5 & 6 is the following:
2/3 hourly rate (or at least minimum wage) not to exceed $200 per day and $2,000 in total
4.
5.
6.
Attach documentation required to support your request. *
Maximum upload size: 52.43MB

For example, a notice of closure or unavailability from the employee’s child’s school, place of care, or child care provider, including a notice that may have been posted on a government, school, or day care website, published in a newspaper, or emailed to the employee from an employee or official of the school, place of care, or child care provider.

C. CHILD SECTION

Completed the Child Section below. “Child” means the employee’s son or daughter who is (i) under 18 years of age, or (ii) at least 18 years of age and is incapable of self-care because of a mental or physical disability.

D. AMOUNT OF LEAVE REQUESTED

Or, If consecutive days are not requested, please list individual days.

E. CERTIFICATION BY EMPLOYEE

I received a copy of the company’s Families First Coronavirus Response Act Policy.

I hereby state and represent that I am unable to work, including telework because of the qualified reason(s) for leave identified above.

I understand that this EPSL shall cease beginning with my scheduled work shift immediately following the termination of the need for paid sick time identified above.

I certify that the information I provided above is true and correct, and that any documentation I submitted is true and correct to the best of my knowledge. I understand that my failure to provide truthful information on this form, or my usage of Emergency Paid Sick Leave for any purpose other than those describe above, may result in disciplinary action, including termination.

F. IMPORTANT INFORMATION

MEDICAL DOCUMENTATION: If you submit medical documentation in support of your request, it should be signed by a licensed HCP and state that you qualify under one of the designated reasons for EPSL. Such documentation need not include any explanation about a particular illness, injury, or other medical condition. You do not need to provide personal medical information. Moreover, recognizing the difficulty of obtaining medical documentation in the current environment, the alternative information requested may be sufficient to support your request.

RETALIATION PROHIBITED: The company will not take adverse action against you for requesting EPSL, using EPSL, or attempting to exercise any right under the EPSLA. If you believe you are being retaliated against for these reasons, notify HR immediately.

OTHER LEAVE: The Company will not require you to use any other type of paid leave prior to using EPSL. EXPIRATION: EPSL is available starting on April 1, 2020. The Act expires on December 31, 2020. You will not be entitled to cash out unused EPSL at the end of 2020 or upon separation from employment.

Completed By HR