Northland Concrete and Masonry
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FFCRA COVID-19 Paid Sick Time Form

  • Pay rate is based n 2019 average.
  • ** only submit for days you are off work.
  • Maximum 2 weeks/80 hours total

  • List the name of the governmental entity that issued the quarantine or isolation order:
  • 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.
  • 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.
  • Reset signature Signature locked. Reset to sign again
  • 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

“The philosophy that a company is only as good as its people puts NCM at the top of its industry.”

EMPLOYMENTEMPLOYMENT
”NCM is always looking for top quality employees”

NCM CV-19 PLAN

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Northland Concrete & Masonry Company

1125 Stagecoach Road
Shakopee, MN  55379
Main Office: (952) 890-1650
Fax: (952) 890-1699
Email: info@northlandcm.com

27077 Katie Rd
Tea, SD 57064
Main Office: (605) 570-1433
Email: Info.northlandcm@gmail.com

Office Hours

Monday-Friday: 8:00-5:00

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