DAS Iowa Department of Administrative Services



Section 1: General information

The Families First Coronavirus Response Act, provides employees with access to EPSL for certain leave requests related to the COVID-19 pandemic. EPSL is available for immediate use by eligible employees. Full-time employees are eligible for up to 80 hours of EPSL. Part-time employees are eligible for EPSL in an amount equal to the number of hours the employee works on average over a two week period.

Section 2: Employee Request

To request emergency paid sick leave as provided under the Families First Coronavirus Response Act and the State of Iowa Leave

Policy, please complete the following request form and submit to your supervisor and/or human resources contact as soon as possible before leave commences. Verbal notice will be accepted until a form can be provided. Documentation supporting the need for leave may be requested, as described in the FMLA Leave Expansion and Emergency Paid Sick Leave Policy. Please type or print on this form.

|Employee Name: |      |Employee ID#: |      |

|Employee Email: |      |Employee Phone#: |      |

|Department: |      |Supervisor: |      |

|Date Leave Began: |      |Expected Date of Return: |      |

|The amount of emergency paid sick leave being requested, not to exceed 80 hours: |      |

I am requesting this EPSL due to my inability to work or telework because (check the appropriate reason below):

1) I am subject to a federal, state, or local quarantine or isolation order related to COVID-19.

|Name of gov. agency: |      |Date of isolation order: |      |

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

|Name of health care provider advising of quarantine: |      |

3) I am experiencing symptoms of COVID-19 and seeking a medical diagnosis.

|Date I was tested/will be tested for COVID-19: |      |

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

|Name of gov. agency: |      |Date of isolation order: |      |

|Name of health care provider advising of quarantine: |      |

|Name of individual: |      |Relation to individual: |      |

5) I am the only person available to care for my child (age 14 or under) whose school or place of care has been closed,

or my childcare provider is unavailable due to COVID-19 precautions. This option may also qualify for Expanded

FMLA and you should notify the Reed Group.

|Name/Address of school or place of care: |      |

|Name/Address of child caregiver: |      |

|Name of child: |      |Age: |      |

|Name of child: |      |Age: |      |

|Reason no other suitable person is available and/or special circumstances to care for child age 15-17: |

|      |

6) I am experiencing another substantially similar condition specified by the Secretary of Health and Human Services.

|Provide details regarding the need for this leave: |

|      |

Section 3: Provisions

Time taken must be full day’s continuous leave for all reason except number 5.

Optional: I wish to take intermittent leave for reason #5 above, during the following days and hours.

|Monday |Tuesday |

|      |I understand I will be given state premium sharing toward the cost of health insurance while utilizing paid leave. |

I hereby certify that the above information is accurate and complete. I understand falsification of any information given may lead to disciplinary action.

|Employee signature: |      |Date: |      |

|Supervisor signature: |      |Date: |      |

|HR Dept. Rep signature: |      |Date: |      |

GENETIC INFORMAITON NONDISTCRIMINATION ACT OF 2008 DISCLOSURE

The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for information. “Genetic information” as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.

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