EXPLANATION OF REQUEST FORM FOR LEAVE DUE TO THE CORONAVIRUS
The Families First Coronavirus Response Act (“FFCRA”) includes the Emergency Paid Sick Leave Act. Employees are eligible for up to two weeks (80 hours or a part-time employee’s two-week equivalent) of fully or partially paid Emergency Paid Sick Leave if unable to work or telework because of one of the following six reasons:
- The employee is subject to a Federal, State, or local quarantine or isolation order related to COVID-19.
- The employee has been advised by a health care provider to self-quarantine due to concerns related to COVID-19.
- The employee is experiencing symptoms of COVID-19 and seeking a medical diagnosis.
- The employee is caring for an individual who is subject to paragraphs (1) or (2).
- The employee is caring for a son or daughter of such employee if the school or place of care of the son or daughter has been closed, or the childcare provider of such son or daughter is unavailable, due to COVID-19 precautions.
- The employee is 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 Families First Coronavirus Response Act (FFCRA) also includes the Emergency Family and Medical Leave Expansion Act. Employees who have been employed for at least 30 days prior to their leave request may be eligible for up to 12 weeks of Emergency Family and Medical Expanded Leave (“FMLA+”) for reason #5 above. Your eligibility for FMLA+ depends on how much FMLA leave you have already taken during the 12-month period as defined by the Company’s FMLA policy. Similarly, any FMLA+ leave that you take under the FFCRA may be counted as part of your allotted annual FMLA leave.
Pay for leave under the FFCRA will be based on the higher of the employee’s regular rate of pay, or the applicable state or Federal minimum wage, paid at:
• 100% for qualifying reasons #1-3 above, up to $511 daily and $5,110 total;
• 2/3 for qualifying reasons #4 and 6 above, up to $200 daily and $2,000 total;
• 2/3 for qualifying reason #5 above, up to $200 daily and up to $12,000 total when Emergency Paid Sick Leave and FMLA+ are combined.
A part-time employee is eligible for leave under the FFCRA for the number of hours that the employee is normally scheduled to work over the leave period.
Requests for leave to be taken on an intermittent basis will be considered by management on a case-by-case basis.
If you wish to request leave under the FFCRA, complete the attached form and submit it to Human Resources. Any supporting documentation should be submitted as well.
REQUEST FOR LEAVE DUE TO THE CORONAVIRUS
To request leave as provided under the Families First Coronavirus Response Act (“FFCRA”) complete, sign, and submit this form to the Human Resources Department as early as possible. If necessary, verbal notice will be accepted until a completed form can be provided.
Employee Name (print clearly): ________________________________________________ Department: ________________________
Manager: _____________________________ Leave Start Date: _______________________ Estimated Leave End Date: ________________
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PART ONE: (Leave to care for a child because of a school closure or unavailability of childcare due to due to COVID-19).
❏ I need to take leave because I am caring for my child whose primary or secondary school or place of care has been closed, or whose childcare provider is unavailable due to COVID–19 precautions. By signing this Request, I represent that no other person will be providing care for the child/children listed below during the period for which I am seeking paid leave.
❏ I wish to request ______ (maximum of 12) weeks of leave under the FFCRA’s Emergency Family and Medical Leave Expansion Act (“FMLA+”).
Child’s Name
Age
Name of School/Child Care Provider
If all the children listed above are at least age 15 or older, include any special circumstances that exist requiring that you provide care. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
❏ I have attached documentation supporting my request. (This may include, for example, a notice that the child’s school or day care has been closed from a website, newspaper, or an email or note to parents from an official or employee of the school, place of care, or childcare provider.) PAY DURING LEAVE: The first two weeks of FMLA+ leave will be unpaid unless I elect one of the following options:
❏ During the first two weeks of FMLA+, I request to take FFCRA Emergency Paid Sick Leave.
❏ During the first two weeks of FMLA+, I request to use up to ______________hours (80 hours maximum) of any applicable Company-provided paid leave that I have available, and then take the remainder as [choose one] ❏ FCRA Emergency Paid Sick Leave / ❏ unpaid leave.
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PART TWO: (Leave for other defined reasons related to COVID-19).
I request ___________ hours (maximum of 80) of FFCRA Emergency Paid Sick Leave because:
❏ I am subject to a federal, state, or local quarantine or isolation order related to COVID–19. (If a stay in place or shelter at home order results in closure or reduction in staff, the reason the employee is unable to work is because of the order’s impact on the company, not on the individual employee.)
Governor’s Executive Order or a local Stay Home – Work Safe Order do not qualify as a quarantine or isolation orders.) Identify the governmental entity issuing the order:
____________________________________________________________________________________
❏ I have been advised by a health care provider to self-quarantine due to concerns related to COVID–19. Include the health care provider’s:
Name: __________________________________ Address: ________________________________ Phone #: ________________________________
❏ I am experiencing symptoms of COVID–19 and seeking a medical diagnosis.
❏ I am caring for an individual who is subject to either number 1 or 2 above. Include the individual’s:
Name: _____________________________________ Relation to Employee (It doesn’t have to be a relative): ________________________________
❏ I am experiencing another substantially similar condition specified by the secretary of health and human services. Include an explanation: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
❏ I have attached the following documentation in support of my request: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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PART THREE: (Intermittent leave request)
❏ I would like to take the requested FFCRA leave on an intermittent basis, and…
❏ Report to work when not on intermittent leave.
❏ Telework when not on intermittent leave.
While on leave, I would be available to work as follows: (Describe your availability. Here are some examples: I am available to telework 4 hours a day from 7:00 a.m. to 9:00 a.m. and from 4:00 p.m. to 6: 00 p.m. I am available to report to work for my full shift on Tuesdays and Thursdays.)
___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________
I swear or affirm that the information contained in this Request for Leave Under the Families First Coronavirus Response Act is accurate and complete to the best of my knowledge.
___________________________________________________________________ ______________________________________
Employee Signature Date
