COVID-19 Related Absence Request (RCSD)

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This form is to be used on absence requests related to COVID-19 that are made through March 31, 2021. The Families First Coronavirus Response Act enacted on March 18, 2020 and effective April 1, 2020 for paid leave, increases employee access to an expansion of the Family Medical Leave Act and provides access to Emergency Paid Sick Leave requests related to the COVID-19 pandemic. The FFCRA expired December 31, 2020, but employers have the option to extend Covid leave through March 31, 2021. On January 8, 2021 in a special called board meeting, the RCSD Board voted to extend Covid leave to any employee in need who had not already exhausted the allowable leave. This form needs only be completed if your absence request is related to COVID-19. Documentation supporting the need for leave will be requested and required. Email cbeeland@rcsd.ms or turn in to your timekeeper all relevant supporting documentation applicable to your leave request (COVID-19 test results for self or that of the family member you are caring for, or documentation of school or daycare closure related to COVID-19).

Email *

Explanation of Eligible COVID-19 related leave

Employee Name *

Employee Position/Title (ie., teacher, cafeteria cashier, bus driver, etc.) *

Employee grade level, if teacher

Is this your first year as an employee with RCSD? *

Yes

School or department *

I am unable to work and am requesting leave for the following reasons related to COVID-19:

I have been advised by a health care provider to self-quarantine related to exposure or diagnosis of COVID-19.

I am experiencing COVID-19 symptoms and am seeking medical diagnosis.

I am caring for an individual who is subject to Federal, State, or Local quarantine order related to COVID-19 or who has been advised by a health care provider to self-quarantine due to concerns related to COVID-19.

I have a child who is under the age of 18 years of age, whose school or place of care has been closed, or whose child care provider is unavailable due to a COVID-19 emergency declared by either a Federal, State, or Local authority.

Clear selection

My first date of absence from work related to a qualifying COVID-19 allowable reason *

YYYY

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