EMERGENCY PAID SICK LEAVE REQUEST FORM FOR COVID …



EMERGENCY PAID SICK LEAVE REQUEST FORM FOR COVID-19-RELATED LEAVEEffective for requests made on or after April 1, 2020 through December 31, 2020.Date: Employee ID: Name (please print): Employee Title/Position: Employee Supervisor: I am unable to work, including engaging in telework and would like to request emergency paid sick leave because (check all that apply). All questions must be fully answered to qualify of the leave: (1) I am subject to a federal, state, or local quarantine or isolation order related to COVID-19;Please provide the name of the government entity:_____________________________________________________________________ (2) I have been advised by a health care provider to self-quarantine because of COVID- 19;Please provide the name of the health care professional advising self-quarantine ___________________________________________________________________________ (3) I am experiencing symptoms of COVID-19 and seeking a medical diagnosis; (4) I am caring for an individual who is subject to an order as described in subparagraphor has been advised as described in paragraph (2).Please provide the name of the person that has been advised to self quarantine________________________________________________________________________________Please provide that person’s relationship to you__________________________________________Please provide the name of the government entity or health care professional that ordered the person to self-quarantine: _________________________________________________________________ (5) I am 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 child care provider of such son or daughter is unavailable, due to COVID–19 precautions;Please provide the name and age of the child(ren) that you need to care for _________________ _____________________________________________________________________________Please provide the name of the school or place of care that has closed _____________________________________________________________________________Is anyone else able to care for the child _____________________________________________If the child is older than 14 please provide the special circumstances that require you to provide care__________________________________________________________________________ (6) I am experiencing any other substantially similar conditions as specified by the Secretary of Health and Human Services, in consultation with the Secretaries of Labor and Treasury.Dates of Leave Requested: to If you are requesting intermittent leave, then please indicate what days of the week and/or time you are available to work. I am requesting intermittent leave and am available to work on and/or from:_______________________________________________________________________________ _______________________________________________________________________________COMPENSATION PROVISIONSEPSL will be paid at an employee’s regular rate, up to $511 per day, where leave is taken for reasons (1), (2), and (3) above (own illness or quarantine)Employee will receive 2/3rds of their regular rate, up to $200 per day, where leave is taken for reasons (4), (5), or (6) above (care for others or school closures).It is unlawful for any employer to require the employee to find a replacement, discharge, discipline, or in any other manner discriminate against any employee taking leave in accordance with this Act. I request to utilize my accrued leave to supplement the reduced compensation for this leave period.Employee Signature: Please return this form to: ................
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