Request for Emergency Paid Sick Leave (Coronavirus)

August 5, 2020

To request emergency paid sick leave as provided under the Families First Coronavirus Response Act and [Company Name]'s Emergency Paid Sick Leave Policy, please complete the following request form and submit to your manager or the human resources department either prior to leave or [choose one of the following phrases: as soon as possible after leave commences/within one day of leave commencing].  Verbal notice will be accepted until a form can be provided.

Documentation supporting the need for leave must be included with this request, as described in the FMLA Leave Expansion and Emergency Paid Sick Leave policy.


Employee Name (print clearly): ________________________________________________

Department: ______________________________

Manager: ________________________________

Requested Leave Start Date: ________________                End Date: __________________

The amount of emergency paid sick leave being requested is __________ hours.

❏ I wish to take intermittent leave for reason #5 below, during the following days and hours


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

❏ 1) I am subject to a federal, state, or local quarantine or isolation order related to COVID–19.

❏ 2) I have been advised by a health care provider to self-quarantine due to concerns related to COVID–19.

❏ 3) I am experiencing symptoms of COVID–19 and seeking a medical diagnosis.

❏ 4) I am caring for an individual who is subject to either number 1 or 2 above.

❏ 5) I am caring for my child whose primary or secondary school or place of care has been closed, or my childcare provider is unavailable due to COVID–19 precautions; and,

❏ I attest that no other suitable person is available to care for my child during the requested period of leave.

❏ I attest special circumstances exist requiring my need for leave to care for a child
ages 15-17.

❏ 6) I am experiencing another substantially similar condition specified by the secretary of health and human services.


I have attached documentation supporting my need for leave.

Employee Signature                                                                                             Date                ___    

Manager Signature                                                                                               Date             ___       

HR Department Rep. Signature                                                                           Date                           

Employee Statement Supporting Leave

I,                                                                         , provide the following information in support of my request for emergency paid sick leave (complete all that apply):

Leave due to a government-issued quarantine or isolation order

Name of the issuing government agency for the quarantine or isolation order:


Effective dates of the order: ______________________________________


Leave due to a health care provider's advice to self-quarantine

Name of the health care provider advising me or the individual I am caring for to


               Written documentation is available and attached:             ❏Yes     ❏No     

Name and relation of the individual who I am needed to care for:

               Name:_____________________ Relation: ________________________

Leave due to a school or place of child care closed due to COVID-19

Name of school or place of care:


Name of child caregiver unavailable due to concerns related to COVID-19:


Name and age of child or children I am needed to care for:

               Name: ___________________________________ Age: _____________

               Name: ___________________________________ Age: _____________ 

               Name: ___________________________________ Age: _____________

No other suitable person is available to care for my child for the requested leave period due to:



The special circumstances requiring my need for leave to care for a child ages 15-17 are:



Leave due to a substantially similar condition specified by the secretary of health and human services

Provide details regarding the need for this leave:



I attest that the above information is accurate and complete. I understand falsification of any information given may lead to disciplinary action.

Employee Signature: ________________________________ Date: _____________                               


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