Request for Emergency Paid Sick Leave under FFCRA
To request emergency paid sick leave as provided under the Families First Corona Response Act, please complete the following request form and submit to the Risk Management Department as soon possible before leave commences.
Employee Name *
Your answer
Employee ID # *
Your answer
Contact Information (Phone number / Email) *
Your answer
Department / Campus *
Your answer
Supervisor *
Your answer
Requested Leave Start Date *
MM
/
DD
/
YYYY
Estimated End Date *
MM
/
DD
/
YYYY
Amount of emergency paid sick leave being requested is (hours)
Your answer
The reason for this emergency paid sick leave request is (check the appropriate reason below) *
Please note that additional documentation will be required and will depend on which option you are using above.
Today's Date *
MM
/
DD
/
YYYY
Submit
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