Request for Coronavirus-Related Paid Sick Leave

Editor's Note: This sample form is intended for use by employers who choose to provide employees with FFCRA-like leave. The tax credits for offering this leave expired on Sept. 30, 2021; however, employers may choose to continue providing leave voluntarily. 

Request for Coronavirus-Related Paid Sick Leave

To request paid sick leave for absences related to the coronavirus, please complete the following request form and submit to your manager or the human resources department either prior to leave or as soon as possible after leave commences. Verbal notice will be accepted until a form can be completed.

Documentation supporting the need for leave must be included with this request.

Employee name (print clearly): _______________________________________________

Department: _____________________________

Manager: ________________________________

Requested leave start date: ________________                End date: __________________

Number of hours of paid sick leave requested: ___________________________________

I am requesting this paid sick leave due to my inability to work (or telework) because (check the appropriate reason below): 

• I am experiencing symptoms of COVID–19.
• I have tested positive for COVID-19 (with or without symptoms).
• I am obtaining a COVID-19 vaccination.
• I am recovering from an illness related to receiving a COVID-19 vaccination.
• I am caring for an individual who is experiencing symptoms of COVID-19 or has tested positive for COVID-19.
• I have been advised by a health care provider to self-quarantine due to concerns related to COVID–19.
• Other: _____________________________________________________________
  
  

Employee signature: ____________________________   Date: ____________________

Manager signature: _____________________________   Date: ____________________

HR Manager signature: __________________________   Date: ____________________