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□ <br />□ <br /> <br /> <br /> <br /> <br />Form to Request FMLA for <br />COVID-19 <br /> <br /> <br />Starting on April 1, 2020, if you are unable to work because of the COVID-19 pandemic, you <br />may be eligible for a partially paid leave of absence through the Family and Medical Leave Act, <br />under recent federal legislation. If eligible, you may take up to 12 weeks of leave for limited <br />reasons described in the new federal legislation. The first ten (10) days of emergency FMLA <br />leave is unpaid, but you may elect to substitute accrued vacation, comp, flex time, and or sick <br />leave under this section to receive pay. The remaining ten weeks are paid at 2/3 your average <br />rate of pay, capped at $200 per day. <br /> <br />To be eligible for this FMLA leave, you must: <br /> <br />Have worked for the City for at least 30 days; and <br /> <br />Be unable to work because you are caring for your minor child since your child’s school or <br />daycare closed or your childcare is unavailable due to COVID-19. <br /> <br />Please note that Human Resources may ask for documentation confirming your eligibility <br />for this leave. <br /> <br />Request Leave to Begin Date: <br /> <br />Anticipate Returning to Work Date: <br /> <br />Employee’s Name (Printed): <br /> <br />Employee’s Signature: