HomeMy WebLinkAbout2022 COVID FMLA FormEmployee name:
Division:
Date of Hire
City of Sebastian
FMLA — Corona Virus
Paid Sick Leave Request
(A separate request must be submitted for each pay period)
Employee #:
Job Title:
I am: Full Time Part Time Temporary -- I work hours biweekly
I am unable to work and am requesting FMLA leave due to the CORONA Virus for the pay period
to for the following reason (check one). You must include supporting
documentation of the quarantine or isolation order, name of health care provider, etc.
1) 1 have been advised by a health care provider to self -quarantine due to a positive test result for COVID or self -
tested and have a positive result;
2) 1 am experiencing COVID-19 symptoms and seeking a medical diagnosis;
3) 1 am caring for a family member who has tested positive for COVID.
Please include supporting documentation of the need to quarantine.
Specify Dates & Hours of FMLA due to the CORONA Virus. - The Cares Act section related to the Corona Virus — FFCRA
— ended December 31, 2020. Therefore, if you become infected with the virus, you will have to use your own
sick/vacation time to be paid. According to the CDC Guidelines you can return to work after quarantining for 5 days, if
after a 24 hour period without fever reducing medication, you do not have a fever, and/or you receive a negative result.
A doctor's note is needed to return to work. In addition, you will have to wear a mask for 5 days.
Sun.: Mon.: Tues.: Wed.:
Thurs.: Fri.: Sat.:
Sun.: Mon.: Tues.: Wed.:
Thurs.: Fri.: Sat.:
I attest the above information is true and correct:
Employee Signature
Date
Supervisor Signature
Date
When completing the ADP Timesheet, please add a Note to indicate if a COVID Absence and indicate the type of leave
you would like to use.