COVID-19 Sick Leave Reimbursement Request Form
Submit your request for reimbursement of eligible COVID-19 sick leave. Please complete all fields accurately. This form does not collect sensitive identifiers or medical record details.
Full Name
*
First Name
Last Name
Work Email Address
*
example@example.com
Department or Position
*
Supervisor or Manager Name
*
Start Date of COVID-19 Sick Leave
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
End Date of COVID-19 Sick Leave
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Total Number of Sick Leave Days Requested
*
Reason for Sick Leave (COVID-19 related)
*
Please Select
Positive COVID-19 Test
COVID-19 Symptoms
Quarantine due to Exposure
Other COVID-19 Related Reason
Amount Requested for Reimbursement (USD)
*
Upload Supporting Documentation (e.g., doctor’s note, positive test result)
*
Upload a File
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of
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