Policy 409.2E1

EMERGENCY PAID SICK LEAVE REQUEST FORM UNDER THE FAMILIES FIRST CORONAVIRUS RESPONSE ACT (FFCRA)

Name: _______________________________________

Anticipated Begin Date: _________________________

Expected Return to Work Date: ___________________
 

Employee Request for Leave at Full Pay Employees satisfying one of the three standards noted below are eligible for two weeks of leave capped at 80 hours paid at the employee's full regular compensation rate. For a part-time employee it is the number of hours equal to the average number of hours that the employee works over a typical two-week period. Please select the applicable reason and follow the related instructions. I am unable to work or telework for the following reasons: ___I am quarantined pursuant to Federal, State, or local government order. ___I am quarantined on the advice of a health care provider due to COVID-19 concerns. ___I am experiencing COVID-19 symptoms and seeking a medical diagnosis. Please attach the applicable government order or documentation from medical provider corresponding to the item(s) selected.  If you are experiencing symptoms and seeking a medical diagnosis, please identify your symptoms and the date of your medical appointment.

 

Employee Request for Leave at 2/3 Pay Employees satisfying one of the three standards noted below are eligible for two weeks of leave capped at 80 hours paid at the 2/3 of the employee's regular compensation rate. For a part-time employee it is the number of hours equal to the average number of hours that the employee works over a typical two-week period. Please select the applicable reason and follow the related instructions. I am unable to work or telework for the following reasons:  ___ I need to care for an individual subject to quarantine pursuant to Federal, State, or local government order or advice of a health care provider due to COVID-19. I represent that no other person will be providing care for the individual during the period for which the I am receiving Emergency Paid Sick Leave. Please attach the applicable government order or documentation from medical provider.  ___ I am experiencing a substantially similar condition as specified by the Secretary of Health and Human Services, in consultation with the Secretaries of the Treasury and Labor. Please attach the applicable government order or documentation from medical provider. ___ I am unable to work or telework because I need to care for my child under age 18 because my child's elementary or secondary school, childcare provider, or child's place of care has been closed or is unavailable due to COVID-19. During this period of unavailability or closure, I represent that no other person will be providing care for my child during the period for which I am receiving Emergency Paid Sick Leave. If the age of one or more of the children is between 14 and 18, the following special circumstances exist requiring me to care for the child during daylight hours: Please attach notice or documentation related to the unavailability of the school, daycare, place of care or person providing care to the child. The District reserves the right to request confirmation regarding the nature of the closure or unavailability.  lf you are requesting 2/3 paid leave in conjunction with Expanded Family Medical Leave to care for a child under the age of 18 affected by school or care closure due to COVID-19, please complete the “Expanded Family and Medical Leave Request Form’ to submit with this form.

 I acknowledge that the above information is true to the best of my knowledge. 

Signed: _________________________________________

Date: ___________________________________________ 

Note:  This type of emergency paid sick leave is only available through passage of the federal Families First Coronavirus Response Act and will expire on December 31, 2020.  After that date, this exhibit should be removed from policy 409.2, as the benefit will no longer be available to employees.

EXPANDED FAMILY AND MEDICAL LEAVE REQUEST FORM UNDER THE FAMILIES FIRST CORONAVIRUS RESPONSE ACT (FFCRA)

Name: _______________________________________

Anticipated Begin Date: _________________________

Expected Return to Work Date: ___________________ 
 

Employees may be entitled to expanded family medical leave in accordance with the Families First Coronavirus Response Act (FFCRA) if the employee satisfies eligibility standards.

 

Reason for Leave 

Employees satisfying the standards below are eligible for 12 weeks* of leave. The first two weeks of the leave are unpaid unless the employee selects available options in the next box. The remaining 10 weeks of leave are paid at 2/3 of the employee's regular compensation rate unless other options are selected on this form. Please select the applicable reason and follow the related instructions.

I,___________________, request family and medical leave because I am unable to work or telework because I need to care for my child(ren) under 18 because my child(ren)’s elementary or secondary school, childcare provider, or child’s place of care has been closed or is unavailable due to COVID-19. During this period of unavailability or closure, I represent that no other person will be providing care for my child during the period for which I am receiving expanded family medical leave benefits.

If the age of one or more of the children is between 14 and 18, the following special circumstances exist requiring me to care for the child during daylight hours: 
_______________________________________________________________________________________

_______________________________________________________________________________________                                                                   

Please attach notice or documentation related to the unavailability of the school, daycare, place of care or person providing care to the child. The District reserves the right to request confirmation regarding the nature of the closure or unavailability.

* An employee who qualifies for and utilizes the Emergency Paid Sick Leave provisions of the FFCRA, is entitled to an additional 10 weeks of Emergency FMLA.

 

Substitution of Paid Leave for the First Ten Days of Expanded Family Medical Leave

In accordance with the FFCRA, the first ten days of expanded family medical leave is unpaid, however you may be eligible to use Emergency Paid Sick Leave provided through the FFCRA to cover this period at 2/3 of full pay. In the event you have already used Emergency Paid Sick Leave, you are permitted to use available District-provided paid leave to cover this period at full pay. Please indicate if you would like to use paid leave during the first 10 days of your absence and how many hours you plan to use. Requested leave is subject to availability based on confirmation by the School District. If requesting Emergency Paid Sick Leave, please complete and submit an “Emergency Paid Sick Leave Request Form.” 

___Emergency Sick Leave    ___  Sick Leave          ___  Personal Leave 

Supplement 2/3 Pay with Accrued District Leave

Employees may choose to supplement the 2/3 pay provided through expanded family medical leave with accrued District leave to earn full compensation. Please indicate if you would like to use paid leave during your expanded family medical leave to supplement your 2/3 expanded family medical leave compensation. Requested leave is subject to availability based on confirmation by the District.

 ___Emergency Sick Leave   ___  Sick Leave          ___   Personal Leave

After completing the first ten days of expanded family medical leave, an employee may choose to take 10 weeks of continuous leave under expanded family medical leave for the reason indicated above. Continuous leave means the employee will not complete any District duties during this period but will be compensated based on the options selected above.

An employee may also choose to take 10 weeks of intermittent leave only with the District’s permission. Intermittent leave means an employee will complete some District duties on a modified schedule as approved by the employee's supervisor. When using intermittent leave, the employee will receive full regular pay for hours worked and 2/3 of regular pay during periods on expanded family medical leave unless supplemented in a manner noted above.

I am requesting (choose one):

___ continuous leave

___ intermittent leave

If your need for leave is intermittent, please describe the requested schedule for your intermittent leave:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
 

I acknowledge that the above information is true to the best of my knowledge.

Signed ________________________________________________________

Date __________________

Note:  This type of emergency paid sick leave is only available through passage of the federal Families First Coronavirus Response Act and will expire on December 31, 2020.  After that date, this exhibit should be removed from policy 409.2, as the benefit will no longer be available to employees.