Request for Families First Coronavirus Response Act (FFCRA)

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EMERGENCY PAID SICK LEAVE (EPSLA) -----EPSLA pays up to 80 hours (prorated for part-time employees) paid at 100% of the employee's regular rate of pay, capped at $511 per day ---- QUALIFYING REASONS FOR LEAVE (Under the FFCRA, an employee qualifies for paid sick time if the employee is unable to work (or unable to telework) due to need for leave because the employee:

Is subject to a Federal, State, or local quarantine or isolation order related to COVID-19; Supporting Documentation: A copy of the quarantine or isolation order

Has been advised by a health care provider to self-quarantine related to COVID-19; Supporting Documentation: Written documentation from the health care provider who advised you to self-quarantine for COVID-19 and related reason

Is experiencing COVID-19 symptoms and is seeking a medical diagnosis; Supporting Documentation: Written documentation from the health care provider that you are experiencing symptoms of COVID-19 and are seeking a medical diagnosis

Leave Requested Dates - FROM --- TO

EMERGENCY FAMILY & MEDICAL LEAVE ACT EXPANSION (EFMLEA)----EFMLEA pays partial pay of 2/3 of salary with a cap of $200 daily. ----- QUALIFYING REASONS FOR LEAVE: Under the FFCRA, an employee qualifies for paid sick time if the employee is unable to work (or unable to telework) due to a need for leave because the employee:

(1) Is caring for an individual subject to an order described i (1) or self-quarantined as described in (2); (b) has been advised by a health care provider to self-quarantine due to concerns related to COVID-19 see below for supporting documentation needed for option 1

(2) Is caring for a child whose school or place of care is closed (or child care provider is unavailable) for reasons related to COVID-19 - see below for supporting documentation needed for option 2

(3) Is experiencing any other substantially-similar condition specified by the Secretary of Health and Human Services, in consultation with the Secretaries of Labor and Treasury?

Leave Requested Dates: From: To:

(1) Supporting Documentation: (a) copy of the quarantine or isolation order; or (b) written documentation from the health care provider who advised the individual being cared for to self-quarantine due to COVID-19 reasons: LIST BELOW NAME OF INDIVIDUAL BEING CARED FOR AND RELATIONSHIP TO INDIVIDUAL BEING CARED FOR:

(2) Supporting Documentation (a) Notice of closure or unavailability from child(ren)'s school, place of care, or child care provider, including a notice that may have been posted on a government, school or day care website, published in a newspaper, or emailed to you from an employee or official of the school, place of care, or child care provider. LIST BELOW THE NAME(S) OF CHILD(REN) BEING CARED FOR AND A STATEMENT REPRESENTING THAT NO OTHER SUITABLE PERSON IS AVAILABLE TO CARE FOR THE CHILD(REN) DURING THE PERIOD OF REQUESTED LEAVE.

The first 2 weeks of EFMLEA are upaid although employees can elect to use their two weeks of EPSLA. Do you wish to use EPSLA for the first 2 weeks of absence?

Yes

Employees may elect to use personal, compensatory and/or vacation time to supplement EPSLA and EFMLEA pay. Please select below if you wish to use accrued time to supplement EPSLA and EFMLEA

Vacation

Personal

Comp Time

If selecting vacation - list # of hours below:

If selecting personal time - list # of hours below:

If selecting comp time - list # of hours below:

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Request for Families First Coronavirus Response Act (FFCRA)

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