CITY OF LOS ANGELES



CITY OF LOS ANGELESDEPARTMENT OF WATER AND POWERINTRADEPARTMENTAL CORRESPONDENCEDate:Select DateTo:Enter Employee Name and ClassificationFrom:Enter Supervisor Name and TitleSubject:REVISED Paid Administrative Leave Due to COVID-19 and Mandatory Testing (Subject to Change)______________________________________________________________________________In compliance with the LADWP temporary policies in response to the COVID-19 pandemic you are hereby placed on Paid Administrative Leave (PAL) for the following:Check At Least One Box:? Self-reports or shows symptoms of upper respiratory infection (e.g. runny nose, sneezing, coughing, or wheezing) or other flu-like symptoms; or unable to clear the self-screening checklist required for entry to any LADWP facility.? Exposure to a verifiable case of COVID-19 in or outside of the workplace; or employee has tested positive for COVID-19. ? Verifiable travel to an area requiring quarantine at home under the current Center for Disease Control (CDC) guidelines.You are directed to comply with the following:From Select Start Date of PAL to Select End Date of PAL, your reporting location shall be at the address provided by you, between the hours of Enter Start of Shift AM/PM to Enter End of Shift AM/PM for the following working days: Enter WorkweekPlease provide the address of your remote reporting location (ie home): Enter complete Reporting Address, including City State ZipYou are expected to remain at your remote reporting location and available for contact or work assignments during your working days and hours. Your remote reporting address must be at a location that allows you to respond to your LADWP work location within 2-hours when directed to do so.You are expected to return to work on Select an expected Return to Work Date if you are symptom-free, have completed the quarantine period (if applicable), and have received a clearance from the Resource Office to return to work.You shall respond within 30-minutes to any telephone calls or email requests from your manager/supervisor, to the phone number you provide below, in the event LADWP needs to communicate with you during your normal working hours. (Employees, otherwise engaged in a meeting or training, must respond within 30-minutes after completing the other work engagement.)Please provide a phone number where you can be reached: Enter Phone NumberYou shall not enter any LADWP property unless specifically summoned by your manager/supervisor. You are required to check-in and check-out with your supervisor each workday, with the exception of your ASDO, at the time and in the manner prescribed by your supervisor.You will receive your regular rate of pay during this PAL.As a condition of being placed on this PAL, you will be assigned to take a mandatory COVID-19 test, unless the reason that you were placed off of work was due to a positive test result or you came to work with symptoms of upper respiratory infection. (A doctor’s note may be provided in lieu of a COVID-19 test under some situations. Check with the Resource Office to determine if a doctor’s note is sufficient.)You will provide the Resource Office or Occupational Health Services (OHS) with your COVID-19 test result immediately upon receiving it. If you test negative, you will be released to return to work the following business day. Failure to return as instructed will result in personal time off. Additionally, failure to provide a negative test result immediately upon receipt will require you to use personal time off for days that you should have returned to work.If you test positive, the Resource Office will review your case individually. It is your responsibility to obtain a test result prior to your expected return to work date as noted above. Failure to do so will result in use of personal time off.You may opt to use personal time in lieu of PAL for any reason, in which case this policy does not apply to you; however, if you have tested positive for COVID-19, you will be required to provide a clearance prior to returning to work.If you fail to comply with all the terms of this policy, you may be subject to disciplinary action. I have read and understand the above directive. I understand that I must take a mandatory COVID-19 test and provide the results to the Resource Office or OHS prior to my return to work:_____________________________Employee SignatureDateEmployee No. Enter Employee ID-1152651066800If completed telephonically:I certify that I have read verbatim the above directive to the employee and the employee acknowledged understanding of the directive. Further, employee has been directed to obtain a mandatory COVID-19 test prior to his/her return to work date. I have mailed or emailed a copy of this form to the employee. ______________________________ Supervisor/Manager SignatureDatecc: Resource Office ................
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