COVID-19 Leave Request

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If you are unable to work/telework due to COVID-19 related reasons, complete this form on a per pay period basis. HR will enter the dates/hours of leave from this form into Paycor for processing. The COVID-19 Leave Chart on the Human Resources website at https://hr.fvcc.edu/ provides resources to help you determine your leave type.

Questions? Contact us at HR@fvcc.edu.

1. Employee Last Name *

2. Employee First Name *

3. Start Date of Leave *

YYYY

4. End Date of Leave *

YYYY

5. Amount of leave requested *

Full day increments

Partial day increments

6. If you chose partial day increments, please list each date and the amount of leave hours used. *

7. COVID-19 Reason for Leave - (The COVID Leave Chart can be found on the HR website at https://hr.fvcc.edu/). *

EPSLA 1 - Government or health care provider ordered Quarantine or Self-Quarantine of self

EPSLA 2 - Experiencing COVID-19 symptoms and seeking medical diagnosis

EPSLA 3 - Caring for Quarantined Individual on advice of health care provider

EPSLA 4 - Care for son or daughter under the age of 18 due to school or childcare closure for COVID-19 reasons

EPSLA 5 - Experiencing substantially similar COVID-19 symptoms specified by the Secretary of Health and Human Services

EFMLA - Care for son or daughter under the age of 18 due to school or childcare COVID-19 closure

8. If you chose a leave option with 2/3 pay, do you want to supplement your pay using your leave accruals?

Yes

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9. If yes, please indicate the leave accruals to be applied and in which order. For example, #1 Sick leave, #2 Vacation leave, #3 Compensatory leave

10. If you chose an EPSLA 1-3 option of leave, state the name of the governmental entity ordering quarantine or the name of the health care professional advising self-quarantine, and, if the person subject to quarantine or advised to self-quarantine is not you, that person's name and relationship to you.

11. If you chose EPSLA 4 or EFMLA, state the name and age of the child (or children) to be cared for, and the name of the school/childcare that has closed or is unavailable.

12. If you chose EFMLA, please attest to the following: *

I attest that no other person will be providing care for my child(ren) during the period I am receiving family medical leave

I attest that I am unable to work or telework because of a need to provide care for a child older than fourteen during daylight hours due to special circumstances that exist requiring that I provide care for my child

By submitting this form, I acknowledge that the information contained herein is true and correct. I understand that documentation may be requested to verify this leave and I must submit it within five working days. *

By submitting this form, I attest that the information it contains is true and correct. I agree to provide supporting documentation if requested by Human Resources.

Required

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