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FFCRA Emergency Paid FMLA Leave (EMFL)

Request Form

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A. INSTRUCTIONS TO EMPLOYEE

The Company will provide eligible employees with up to 12 weeks of Emergency Family and Medical Leave (EFML) for a qualifying need related to a public health emergency. This is not an additional 12 weeks of leave under the Family and Medical Leave Act (“FMLA”). Rather, it is an additional reason to use leave under the FMLA. If you already have used some FMLA leave within the last 12-months, then any remaining FMLA leave may be used for this new reason. If you already used all 12 weeks of your FMLA leave entitlement for other reasons within the last 12 months, then no additional leave is available for this new reason.

The leave under this policy is limited to circumstances where you are unable to work (including telework) due to your need to care for your minor child or child incapable of self-care because of a mental or physical disability because the child’s school or place of childcare has been closed or the child’s care provider is unavailable due to a public health emergency. Public health emergency means an emergency with respect to COVID-19 declared by a federal, state or local authority.

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B. ELIGIBILITY

Emergency family and medical leave is available to all employees that have been employed by the Company for at least 30 calendar days before the leave is to begin.

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QUALIFYING REASONS FOR EPSL and SUPPORTING DOCUMENTATION / INFORMATION

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 (in the first column) the reason you qualify for EFML.

Attach documentation required to support your request.

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.

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REASON FOR EMERGENCY SICK LEAVE REQUEST

I certify that I am unable to work, or telework because I am caring for my son or daughter due to their school or place of care of the son or daughter has been closed, or the child-care provider of my son or daughter is unavailable, due to COVID-19 precautions.

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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.

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RATE OF SICK LEAVE PAID

2/3 hourly rate (or at least minimum wage) not to exceed $200 per day and $10,000 total over the 10-week period

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C. CHILD SECTION

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If applicable, I hereby represent that my child is over 14 years of age and that special circumstances exist requiring me to provide care to that child during daylight hours.

I hereby represent that no other suitable person will be caring for my child/children during the period for which I am taking emergency sick leave.

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“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.

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COMPENSATION

Unpaid Leave – The first 10 workdays (two weeks) of leave are unpaid, but you may elect to substitute accrued paid leave, including emergency paid sick leave.

Paid Leave – After the first 10 workdays, the next 10 weeks are paid at a rate of two-thirds (2/3) of your regular rate of pay for the number of hours you would otherwise be scheduled to work (with a maximum payment of $200 per day and $10,000 total).

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INTERMITTENT LEAVE

Intermittent Leave While Teleworking – If you are prevented from teleworking your normal schedule of hours because of a
Qualifying Need, the Company will collaborate with you to determine whether it is possible for you to continue working
intermittently and taking Public Health Emergency Leave intermittently.

Intermittent Leave While Needed to Work On-Site – The Company will consider requests for intermittent Public Emergency Leave due to a Qualifying Need on a case by case basis for employees who are needed to work on site to determine whether such intermittent leave can be granted in light of business needs. Such leave is only possible with the Company’s permission and where you and the Company agree upon a schedule for such leave.

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D. AMOUNT OF LEAVE REQUESTED

What is your requested start date?

How many hours are requested?

If consecutive days are not requested, list dates (if known at this time)

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E. HOW TO SUBMIT THIS FORM

Submit the completed form to HR by (1) hand delivery, or (2) email. If submitting by email, attach as a PDF. If you cannot create a PDF, attach a legible photograph of the form (such as one taken on a smart phone).

Please sign and submit this form to HR by (1) hand delivery, or (2) email. If submitting by email, attach as a PDF. If you cannot create a PDF, attach a legible photograph of the form (such as one taken on a smart phone). Please return this completed signed form and additional documentation supporting your leave request to you

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HR Associate [name] at [phone number] [email].

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

Emergency Paid FMLA Leave shall cease beginning with my scheduled work shift immediately following the termination of the need for leave identified above.

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SIGNATURE

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DATE

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G. IMPORTANT INFORMATION

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

[name] at [phone number] [email].

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.

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Completed By HR

Manager confirmed they were unable to work, including telework because of the qualified reason(s) for leave identified.

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The employee has not used any FMLA leave

The employee has used weeks FMLA leave during the current 12 month period for other FMLA-protected reasons, thus they only have weeks of leave available not the full 10 weeks of paid Public Health Emergency Leave.

FMLA Leave Approved for weeks. Unpaid for the first 2 weeks of the 12 weeks.

FMLA Leave Denied & Reason:

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HR’s Associate’s Signature

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DATE RECEIVED

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