FAMILIES FIRST CORONAVIRUS RESPONSE ACT (FFCRA) Request Form
NOTE: If you have tested positive for COVID-19, or believe you have been in Close Contact with an individual who has tested positive for COVID-19, please isolate from others and call your principal/supervisor or the Superintendent's office immediately.

This form is required to:
1. Request protected medical leave due to a COVID-19 related circumstance, OR
2. Engage in a temporary off-campus work assignment as approved by a principal/supervisor and the superintendent.
3. Report a requirement to quarantine (after initial FFCRA protection)

All responses will be kept confidential within the district HR department. However, the district is obligated to communicate COVID-19 diagnosis and Probable Close Contacts to the Arkansas Dept of Health.
Last Name *
First Name *
Date of exposure or onset of symptoms *
MM
/
DD
/
YYYY
This is my first time to be on leave due to COVID *
I have been employed by the district at least 30 days *
Job Classification *
Off-site Work Option (NOTE: If you are able to perform one job off campus (i.e., teacher) but unable to perform another (i.e., bus driver) please fill out a separate form for each position. *
Position (check all that apply to THIS request) *
Required
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