• COVID-19 Emergency Paid Sick Leave Request Form

    Please complete the following EPSL request form and submit your manager or HR department prior to leave.

  • The Families First Coronavirus Response Act (FFCRA or Act) requires certain employers to provide employees with paid sick leave or expanded family and medical leave for specified reasons related to COVID-19. The Department of Labor’s (Department) Wage and Hour Division (WHD) administers and enforces the new law’s paid leave requirements. These provisions will apply from the effective date through December 31, 2020.

    Generally, the Act provides that employees of covered employers are eligible for:

    • Two weeks (up to 80 hours) of paid sick leave at the employee’s regular rate of pay where the employee is unable to work because the employee is quarantined (pursuant to Federal, State, or local government order or advice of a health care provider), and/or experiencing COVID-19 symptoms and seeking a medical diagnosis; or
    • Two weeks (up to 80 hours) of paid sick leave at two-thirds the employee’s regular rate of pay because the employee is unable to work because of a bona fide need to care for an individual subject to quarantine (pursuant to Federal, State, or local government order or advice of a health care provider), or to care for a child (under 18 years of age) whose school or child care provider is closed or unavailable for reasons related to COVID-19, and/or the employee is 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; and
    • Up to an additional 10 weeks of paid expanded family and medical leave at two-thirds the employee’s regular rate of pay where an employee, who has been employed for at least 30 calendar days, is unable to work due to a bona fide need for leave to care for a child whose school or child care provider is closed or unavailable for reasons related to COVID-19.

    Please check Employee Paid Leave Rights to get more detailed information.

  • Employee Info

  • Leave Start Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • End Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • I am requesting this emergency paid sick leave due to my inability to work (or telework) because (check the appropriate reason below)

  • Leave due to a government-issued quarantine or isolation order

    Please provide the name of the issuing government agency for the quarantine or isolation order
  • Order Date
     - -
    2 digit month, 2 digit day, 4 digit year
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  • Leave due to a health care provider's advice to self-quarantine

    Please provide details of the health care provider advising you
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  • Leave due to caring for an individual subject to an order described in (1)

    Please provide details of the individual who I am needed to care for
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  • Leave due to caring for a child whose school or place of care is closed

    Please provide details of the individual who I am needed to care for
  • Name and age of child or children I am needed to care for:
    Rows
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  • Leave due to substantially-similar condition specified by the Secretary of Health and Human Services

    Please provide details about the substantially-similar condition specified by the Secretary of Health and Human Services, in consultation with the Secretaries of Labor and Treasury.

  • By submitting this form, I attest that the above information is accurate and complete. I understand I am entitled to up to two (2) weeks of emergency paid sick leave totally, regardless if I qualify for multiple reasons until December 31, 2020. I understand falsification of any information given may lead to disciplinary actions.

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