FFCRA Leave Request
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To work with this form:
1) Click File, Make a Copy
2) Change the File Name to YOUR NAME (using first and last names) - FFCRA and update the location to the folder on your drive where you want the form.
3) Update the new file with your request information
4) Share the form to covid@usd402.com for processing, making sure you choose EDITOR when sending the form.
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Families First Coronavirus Response Act (FFCRA)
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Emergency paid sick leave and expanded paid FMLA request
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Employee Name:
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Today's Date:Person completing form if other than self:
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Employee statement explaining why they are unable to work or telework because of reason identified above:
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COVID-19 qualifiying reason for the leave request:
SEE LIST OF REASONS BELOW, ENTER # HERE.
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For leave category #1, please identify governmental entity that issued the quarantine order. Attach county health dept. order.
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For leave category #2, please identify health care provider that advised employee to self-quarantine.
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For leave category #3, please identify date of symptom onset.
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For leave category #4, please identify the name of governmental entity or health care provider and the name and relationship of the person being cared for:
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NAME OF ENTITY OR PROVIDERNAME & RELATIONSHIP OF PERSON BEING CARED FOR
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For leave category #5, please provide name of child, name of schools or child care provider that closed, and if the child is over the age of 14 and requested leave is during daylight hours, a statement explaining the circumstances requiring employee to provide care:
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NAME OF CHILDNAME OF CLOSED SCHOOL OR CHILD CARE PROVIDER
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STATEMENT EXPLAINING CIRCUMSTANCE IF CHILD IS OVER 14 YEARS OLD
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Conditions to qualifify employee for leave:
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1.
The employee is subject to a federal, state, or local quarantine or isolation order related to COVID-19. (full pay)
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2.The employee has been advised by a healthcare provider to self-quarantine due to concerns related to COVID-19. (full pay)
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3.The employee is experiencing symptoms of COVID-19 and seeking a medical diagnosis. (full pay)
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4.The employee is caring for an individual who is subject to an order as described in item (1) or has been advised as described in item (2). (2/3 pay)
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5.The employee is caring for his/her son or daughter if the school or place of care of the son/daughter has been closed, or the childcare provider of the son/daughter is unavailable, due to COVID-19 precautions. (2/3 pay)
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6.The employee is experiencing any other substantially similar condition specified by the Secretary of Health and Human Services, in consultation with the Secretary of the Treasury and the Secretary of Labor. (2/3 pay)
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FOR OFFICE USE:
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First day off work:Return to Work Date
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Determination of leave requirement: (check one)
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CaseOnset Date:
+ 10 days minimum
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Household Contact
Original Onset Date:
+24 days minimum
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Non-Household ContactLast Known Contact Date:
+14 days minimum
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Entered Leave :COVID DATES -
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SICK LEAVE DATES -
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Pay Calculation for reasons 4-6 :
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Processor:
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SIGN & DATE
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This is what it should look like when trying to share this form with the district office.
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