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□ <br />□ <br />□ <br />□ <br />□ <br />□ <br /> <br /> <br />Form to Request Federal Paid <br />Sick Leave for COVID-19 <br /> <br />Starting on April 1, 2020, if you are unable to work because of the COVID-19 pandemic, you may <br />be eligible for paid sick leave under new federal legislation. Your leave will be paid at your <br />regular rate of pay, capped at $511 per day, if you need leave for reasons 1-3 below. Your leave <br />will be paid at 2/3 your regular rate of pay, capped at $200 per day, if you need leave for <br />reasons 4-6 below. Full-time employees may take up to 80 hours of paid sick leave for a <br />qualifying reason. Part-time employees may take the number of hours they typically work in an <br />average two-week period. To request paid COVID-19 sick leave, please check the box below that <br />describes the reason you are not able to work: <br /> <br />You are subject to a federal, state, or local quarantine or isolation order related to <br />COVID-19, including but not limited to a “shelter in place” order. <br /> <br /> You have been advised by a health care provider to self-quarantine due to concerns related to COVID-19. <br /> <br /> You are experiencing symptoms of COVID-19 and you are seeking a medical diagnosis. <br /> You are caring for an individual (including but not limited to a family member or member of your household) who <br /> <br />1) is subject to a federal, state, or local quarantine or isolation order related to <br />COVID-19, such as a “shelter in place” order; or <br /> <br />2) has been advised by a health care provider to self-quarantine due <br />to concerns related to COVID-19. <br /> <br /> You are caring for your minor child because your child’s school or daycare closed or your childcare is unavailable because of COVID-19. <br /> <br /> You are experiencing a substantially similar condition, as specified by the U.S. Departments of Health and Human Services, Labor, and Treasury. <br /> <br />Please note that Human Resources may ask for documentation at any point to confirm your <br />eligibility for this leave. If you are unable to work but do not qualify for one of the six <br />reasons above, contact Human Resources to discuss other options for 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: