FFCRA COVID-19 Paid Sick Time Form Employee Name*Pay rate is based n 2019 average.Date Form Completed*Date(s) of Leave Requested*** only submit for days you are off work.Maximum 2 weeks/80 hours totalBox 1 1 - 100% Pay: Employee is subject to a Federal, State, or local quarantine or isolation order (including NCM’s stay at home if you are sick order) related to COVID-19. An employee may only take paid sick leave for this reason if the order causes the employee to be unable to work (or telework) even though the employer has work the employee could perform but for the order. An employee is not eligible for paid sick leave or paid expanded family medical leave if the employer does not have work available as a result of a shelter-in-place or a stay-at-home order. * List the name of the governmental entity that issued the quarantine or isolation order:Box 2 2 - 100% Pay: Employee has been advised by a health care provider to self-quarantine due to concerns related to COVID-19. * List the name of the health care provider who advised you to self-quarantine due to concerns related to COVID-19:Box 3 3 - 100% Pay: Employee is experiencing COVID-19 symptoms and is seeking medical diagnosis from a health care provider. Box 4 4 - 2/3 Pay: The Employee is caring for an individual who is subject to quarantine like those outlined in #1 and #2, above. * Provide the name of the individual being cared for the and relationship to the employee: NameRelationship* If the individual being cared for is subject to a quarantine order as in #1,List the name of the governmental entity that issued the quarantine or isolation order:* If the individual being cared for has been advised to quarantine by a healthcare provider as in #2,List the name of the health care provider advising self-quarantine due to concerns related to COVID-19:Maximum 10 weeks/400 hours total ** 2 week waiting period.Box 5 5 - 2/3 Pay: The Employee is caring for his or her son or daughter whose school whose school or place of care has been closed for a period of time, or whose child care provider is unavailable, for reasons related to COVID-19. * Leave Requested: Paid Sick Leave (available weeks 1-2) Paid EFML (available weeks 3-12) Both * Has the employee been employed for 30 calendar days prior to the leave beginning? Yes No (Note: employed for less than 30 calendar days are not eligible for paid EFML.) * Name and age of the son or daughter being cared for:* If a child is 14 years or older, describe the special circumstances that require care during daylight hours:* Name of the school(s), place(s) of care, or child care provider(s) that has closed or become unavailable:* Employee: Do you affirm that no other suitable person will be caring for the son or daughter during the period for which you take paid sick leave and/or expanded family medical leave? If yes, initial here:Is the employee able to telework? Yes No If no, why not?Due to physical nature of work.I am requesting leave pursuant to the provisions of the Families First Coronavirus Response Act (FFCRA) for the COVID-19 related reason indicated on page 1. I affirm that I am unable to work or telework for the qualified reason(s) indicated. I certify that all information and attestations on this form are true and accurate.Signature*Date Signed*Links to Additional FFCRA Paid Leave Resources FFRCA Paid Leave Information (U.S. Dept. of Labor): https://www.dol.gov/agencies/whd/pandemic/ FFCRA Tax Credit Information (IRS): https://www.irs.gov/newsroom/covid-19-related-tax-credits-for-required-paid-leave-provided-by-small-and-midsize-businesses-faqs
