Employees satisfying one of the three standards noted below are eligible for two weeks of leave capped at 80 hours paid at the employee’s full regular compensation rate. For a part-time employee it is the number of hours equal to the average number of hours that the employee works over a typical two-week period. Please select the applicable reason and follow the related instructions.
I am unable to work or telework for the following reason:
___I am quarantined pursuant to Federal, State or local government order.
___I am quarantined on the advice of a health care provider due to COVID-19 concerns.
___I am experiencing COVID-19 symptoms and seeking a medical diagnosis.
Please attach the applicable government order or documentation from a medical provider corresponding to the item(s) selected. If you are experiencing symptoms and seeking a medical diagnosis, please identify your symptoms and the date of your medical appointment.
Reason for Leave
Employees satisfying the standards below are eligible for 12 weeks* of leave. The first two weeks of the leave are unpaid time unless the employee selects available options in the next box. The remaining 10 weeks of leave are paid at 2/3 of the employee’s regular compensation rate unless other options are selected on this form. Please select the applicable reason and follow he related instructions.
I, _________________________________, request family and medical leave because I am unable to work or telework because I need to care for my child(ren) under 18 because my child(ren)’s elementary or secondary school, childcare provider, or child’s place of care has been closed or is unavailable due to COVID-19. During this period of unavailability or closure, I represent that no other person will be providing care for my child during the period for which I am receiving expanded family medical leave benefits.
If the age of one or more of the children is between 14 and 18, the following special circumstances exist requiring me to care for the child during daylight hours:
Please attach notice or documentation related to the unavailability of the school, daycare, place of care or person providing care to the child. The District reserves the right to request confirmation regarding the nature of the closure or unavailability.
*An employee who qualifies for and utilizes the Emergency Paid Sick Leave provision is entitled to an additional 10 weeks of Emergency FMLA
Approved:
Reviewed: July 27, 2020
Revised:
