This electronic form is designed for extended leave requests. Employees must provide documentation as outlined below.  Employee may be eligible for State of Emergency Leave if he or she is unable to work on-site, remotely, or through an alternative work assignment for a qualifying reason.

1. Employee is sick due to COVID-19 symptoms, have been advised to self-quarantine by a
       healthcare provide or is caring for a dependent with COVID-19 symptoms.
 
     • Documentation from physician for self or dependent.  

2. Employee has childcare or eldercare needs due to COVID-19-related facility closings.

     • Documentation to verify closure of childcare facility.  If student is enrolled in UCPS,
        state “My child(ren) list name(s) is enrolled at, list the school(s).”

     • “My child attends (list child care facility and full address), and it is closed.”

3. Employee is required to report to his/her work-site but is high risk and unable to work
        remotely.

     • Documentation from physician with general statement that employee has a
        medical condition which makes him or her more susceptible to COVID-19.  
        (Medical diagnosis should not be disclosed.)

4. Employee is unable to work on-site or remotely and has not been provided alternative
        remote assignments.
 
     • Appropriate documentation will be requested from Department Head, Principal, or Supervisor.