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Families First Coronavirus Response ActLeave Request FormUpdated April 10, 2020388620210185Part A: To be completed by employee and/or supervisor, and then submitted to human resources.00Part A: To be completed by employee and/or supervisor, and then submitted to human resources.Employee Name Click or tap here to enter text. Title/Agency/Unit Click or tap here to enter text.REASON FOR LEAVE:? 1. Subject to a federal, state or local quarantine or isolation order related to COVID-19.Name of government entity ordering self-quarantine/isolation: Click or tap here to enter text.? 2. Advised by a health care provider to self-quarantine related to COVID-19.Name of health care provider ordering self-quarantine: Click or tap here to enter text.? 3. Experiencing COVID-19 symptoms and seeking a medical diagnosis.Name of health care provider seeking diagnosis from: Click or tap here to enter text.? 4. Caring for an individual subject to a quarantine or isolation order.Name of individual requiring care and relation to employee: Click or tap here to enter text.Name of authorized entity or health care provider ordering the individual to self-quarantine: Click or tap here to enter text.? 5. Caring for son or daughter whose school or place of care is closed or unavailable due to coronavirus-related reasons.Name of child(ren): Click or tap here to enter text.Age of child(ren): Click or tap here to enter text.Name of school, place of care or childcare provider that is unavailable due to coronavirus related reasons and dates of closure: Click or tap here to enter text.? 6. Other Click or tap here to enter text. Please provide a statement explaining why you are unable to work, telecommute or be reassigned related to the reason(s) selected above:Click or tap here to enter text.If you selected Reason #5 above, is there another suitable person who can provide care to your children (please explain): Click or tap here to enter text.TYPE OF LEAVE REQUESTED:?Continuous ?Intermittent ?Reduced Work ScheduleIf intermittent or reduced work schedule, please explain: Click or tap here to enter text.USE OF OTHER LEAVES:If eligible, do you wish to use paid leave under the Emergency Paid Sick Leave Act (EPSLA)?? Yes? NoIf eligible, do you wish to use other paid leave options as defined in the Statewide COVID19 Policy to supplement the benefit in order to receive your full rate of pay under FFCRA and EPSLA (if so, please explain below)?? Yes? NoIf applicable, provide details: Click or tap here to enter text.ANTICIPATED LEAVE DATES:Date leave to start: Click or tap here to enter text. Date of anticipated return to work: Click or tap here to enter text.I certify under penalty of perjury that the information provided to support this request is accurate:Employee Signature: Click or tap here to enter text. Date: Click or tap here to enter text.Employee Instructions: Provide this request to your agency’s human resources contact for review. 388620166370Part B: To be completed by human resource contact.00Part B: To be completed by human resource contact.Hire Date Click or tap here to enter text. Employee’s Classification Title Click or tap here to enter text.Has the employee been employed for at least 30 calendar days? ?Yes ? NoIs the employee a health care provider or first responder? ?Yes ? NoIf yes, please provide details regarding position: Click or tap here to enter text.Is the employee eligible for:Emergency Paid Sick Leave? ?Yes ? No If yes, at what rate?? 2/3 (care for other) ? Full-Rate (care for self)For hour many hours (i.e., full-time, part-time)? Click or tap here to enter text.If no, please explain: Click or tap here to enter text.Emergency Family and Medical Leave Expansion Act (EFMLEA)? ?Yes ? NoIf yes, how many FMLA hours does the employee have available to them? Click or tap here to enter text.If no, please explain: Click or tap here to enter text.Is the employee eligible to take any other leave? (include leave balances as of the end of the last pay period)? Sick Click or tap here to enter text. ? Vacation/Comp/Rhh/OCE Click or tap here to enter text.? Donated Leave Click or tap here to enter text.? Advanced Sick Leave Click or tap here to enter text.? COVID-19 Admin Leave (requires DHR approval) Click or tap here to enter text.HR Contact Name: Click or tap here to enter text. Date: Click or tap here to enter text.HR Instructions:? Review information to determine eligibility and/or request additional information. ? Notify the employee of their eligibility using the Families First Coronavirus Response Act Notice of Eligibility/Designation Notice on DHR’s website. ? Provide instructions to the employee and their supervisor on timesheet coding.? Place a copy of this form with any additional information used to determine employee’s eligibility for leave and the amount of leave (i.e., timesheets, EIS information on part-time/full-time status, etc.) in the employee’s medical file. CC:Medical File ................
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