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FFCRA Emergency Paid Sick Leave (EPSLA)

Request Form

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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 F of this form and submit it to Human Resources. 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.

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B. QUALIFYING REASONS FOR EPSL and SUPPORTING DOCUMENTATION / INFORMATION

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 (in the first column) the reason(s) you qualify for EPSL. Complete column 2 and 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.

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REASON FOR EMERGENCY SICK LEAVE REQUEST

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.

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01 I am subject to a Federal, State, or local quarantine or isolation order related to COVID-19. The name of the government entity that issued the quarantine or isolation order is:

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02 I have been advised by a health care provider (HCP) to self-quarantine due to concerns related to COVID-19. The name of the health care provider who advised me to self-quarantine due to concerns related to COVID-19 is:

The medical document of advisement by HCP is attached.

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03 I am experiencing symptoms of COVID-19 and am seeking a medical diagnosis. Once you have obtained a medical diagnosis please provide name of the health care provider name and results of visit related to COVID-19. (tested, not tested, confirmed positive for COVID-19, etc.)

The medical documents of my diagnosis or my efforts to see a diagnosis is attached.

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04 I am caring for an individual who is subject to a Federal, State, or local quarantine or isolation order related to COVID-19 or has been advised by a health care provider to self-quarantine due to concerns related to COVID-19.

The name of the individual for whom I am caring for is:

Their relationship to me is:

The name of the government entity that issued the quarantine or isolation order, or name of the health care provider who advised the person I am caring for to self-quarantine due to concerns related to COVID-19 is:

The name of the health care provider who advised the person being cared for to self-quarantine due to concerns related to COVID-19 is:

The medical document of advisement by HCP is attached.

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05I am caring for my son or daughter because the 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.

Completed the Section C below.

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06I 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.

The document showing reason is attached.

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RATE OF SICK LEAVE PAID

Hourly rate not to exceed $511 per day and $5,110 in total

2/3 hourly rate (or at least minimum wage) not to exceed $200 per day and $2,000 in total

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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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D. AMOUNT OF LEAVE REQUESTED

What is your requested start date?

How many hours are requested?
(Up to 80 hours for FT employees.)
?

If consecutive days are not requested, list dates (if known at this time) of all days (or ½ days of 4 hours) that you request for EPSL.

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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 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.

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SIGNATURE

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DATE

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G. 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

[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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Paid Sick Leave Approved

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Paid Sick Leave Denied & Reason:

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HR’s Associate’s Signature

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DATE RECEIVED

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