EXPANDED FAMILY AND MEDICAL LEAVE REQUEST FOR UNDER THE FAMILIES FIRST CORONAVIRUS RESPONSE ACT (FFCRA)

Name: _______________________________________

Anticipated Begin Date: _________________________

Expected Return to Work Date: ___________________

Employees may be entitled to expanded family medical leave in accordance with the Families First Coronavirus Response Act (FFCRA) if the employee satisfies eligibility standards.

Reason for Leave

Employees satisfying the standards below are eligible for 12 weeks* of leave. The first two weeks of the leave are unpaid 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 the 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 provisions of the FFCRA, is entitled to an additional 10 weeks of Emergency FMLA.

Substitution of Paid Leave for the First Ten Days of Expanded Family Medical Leave

In accordance with the FFCRA, the first ten days of expanded family medical leave is unpaid, however you may be eligible to use Emergency Paid Sick Leave provided through the FFCRA to cover this period at 2/3 of full pay. In the event you have already used Emergency Paid Sick Leave, you are permitted to use available District-provided paid leave to cover this period at full pay. Please indicate if you would like to use paid leave during the first 10 days of your absence and how many hours you plan to use. Requested leave is subject to availability based on confirmation by the School District. If requesting Emergency Paid Sick Leave, please complete and submit an “Emergency Paid Sick Leave Request Form.”

___Emergency Sick Leave     ___Sick Leave    ___Personal Leave