1910F1 - Emergency Paid Sick Leave Request Form

Last Updated: 11/3/2020 8:49 PM

Belgrade School District - Employee Request Form - Emergency Paid Sick Leave 1910F1

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Employees may be entitled to Emergency Paid Sick Leave in accordance with the Families First Coronavirus Response Act (FFCRA) if the employee satisfies eligibility standards. Employees can complete this form and submit it or any questions to the H.R. Department at the district administration building.

Section 1

  • Employee Name
  • Mailing Address
  • E-Mail
  • Home Phone Number
  • Alternate Phone Number
  • Anticipated Begin Date of Leave
  • Expected Return to work Date

Section 2

EMPLOYEE REQUEST FOR LEAVE AT FULL PAY

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 reasons:

  • I am quarantined pursuant to Federal, State, or local government order.
  • I am quarantined on the advice of a health care provider.
  • I am experiencing COVID-19 symptoms and seeking a medical diagnosis.

Please attach the applicable government order or documentation from medical provider corresponding to the item(s) selected.

Section 3

EMPLOYEE REQUEST FOR LEAVE AT 2/3 PAY


Employees satisfying one of the three standards noted below are eligible for two weeks of leave capped at 80 hours paid at the 2/3 of the employee's 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 applicable instructions.


I am unable to work or telework for the following reasons:

  • I need to care for an individual subject to quarantine pursuant to Federal, State, or local government order or advice of a health care provider. I represent that no other person will be providing care for the individual during the period for which the I am receiving Emergency Paid Sick Leave.
    • Name(s) of the individual(s) being cared for:
  • I am experiencing a substantially similar condition as specified by the Secretary of Health and Human Services, in consultation with the Secretaries of the Treasury and Labor.
    • Please attach the applicable government order or documentation from medical provider corresponding to the item(s) selected.
  • I am unable to work or telework because I need to care for my child under age 18 because my child's elementary or secondary school, childcare provider, or child's place of care has been closed or is unavailable due to a public health emergency. 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 Emergency Paid Sick Leave.
    • Name(s) and Age(s) of Child or Children:
      • 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 School District reserves the right to request confirmation regarding the nature of the closure or unavailability.

If you are requesting 2/3 paid leave in conjunction with Emergency FMLA to care for a child under the age of 18 affected by school or care closure due to public health emergency, please complete an EFMLAform to submit with this form.

Section 4

SUPPLEMENT 2/3 PAY WITH ACCRUED DISTRICT LEAVE


An employee on Emergency Paid Sick Leave at 2/3 pay as noted above, may choose to supplement the 2/3 pay provided through Emergency Paid Sick Leave with accrued District leave to earn full compensation. Please indicate if you would like to use paid leave during your EFMLA absence to supplement your 2/3 Emergency Paid Sick Leave compensation. Requested leave is subject to availability based on confirmation by the School District.

  • Vacation: ____Hours
  • Sick Leave: ____Hours
  • Personal: ____Hours

Section 5

EMPLOYEE CERTIFCIATION AND SIGNATURE


I certify that the above information is accurate and complete. I understand that ifl fail to report for work on or before the scheduled return date indicated above or fail to communicate changes in the schedule with my supervisor, I may be subject to discipline in accordance with School District Policy.

  • Employee Signature
  • Date

Section 6

FOR SCHOOL DISTRICT USE ONLY

  • Request Received By
  • Date
  • Leave Approved By
  • Date
  • Period of Leave
  • Duration and Type of Supplemental Leave to Earn Full Pay Approved

The School District will retain all records related to this leave request for at least 4 years for auditing purposes.

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