Public Health Emergency Leave Request: COVID-19

In response to the COVID-19 public health emergency, the Families First Coronavirus Response Act, adopted by the federal government, provides two new types of public health emergency leave. In addition to existing leave categories, City Schools will offer these two types of public health emergency leave beginning March 30, 2020 and ending January 31, 2021. If forthcoming implementation guidance from the U.S. Department of Labor requires any changes to the information provided below, we will notify all employees. For a quick reference from the U.S. Department of Labor, see this poster: Employee Rights – Paid Sick Leave and Expanded Family and Medical Leave Under the Families First Coronavirus Response Act. An employee is considered unable to work (or telework) when the criteria are met for Emergency Paid Sick Leave and/or Expanded Family Medical Leave and either: • The employee works in a job title where on-site work is required; or • The employee cannot fulfill the duties and responsibilities of their job, even if working from home is available, due to the public health emergency. Instances addressed by public health emergency leave include: • Employee’s Own Health Condition Related to COVID-19 • Employee Caring for an Individual with a Health Condition Related to COVID-19 • Child Care Need Related to COVID-19 If you are completing this form for childcare needs, you will be asked to indicate whether you would prefer to seek continuous (full-time) leave due to childcare needs or intermittent (part-time) leave due to childcare needs. The district will consider your preference and then may approve either continuous, intermittent, or neither type of leave. Please note, if you are approved for leave, your earnings may be impacted. For more information, please go to the U.S. Department of Labor's website at: https://nam05.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.dol.gov%2Fagencies%2Fwhd%2Fpandemic%2Fffcra-employee-paid-leave&data=02%7C01%7Ccahall01%40bcps.k12.md.us%7C5dff84f808104537b30108d7e7d45cd8%7C065bb2f46fe3414fa910f2886305c814%7C0%7C0%7C637232771595282447&sdata=MitKBA5I6IfrYSK3w8lkzkfcZd4VgB7tuzXNn2%2Bx6TU%3D&reserved=0 Those on approved leave through this application to care for someone else, including childcare leave, will be paid at 2/3 pay for the duration of their approved leave.

Employee ID*

First Name*

Last Name*

Employee Email Address*

Best Phone Number*

Assignment Location*

Select

Leave Type Requested*

Select

Requested Date to Begin Leave*

Requested Date to End Leave*

Building/Location Supervisor Name*

Please include the name of your building/location supervisor here.

Building/Location Supervisor Email*

Please include your building/location supervisor's email here.

Employee’s Own Health Condition Related to COVID-19

COMPLETE THIS SECTION IF you are requesting leave for your own health condition related to COVID 19. SKIP THIS SECTION IF you are requesting leave to care for an individual with a health condition related to COVID 19 or requesting leave for child care related to COVID 19.

Leave Reason

Select

Details

Please provide additional details for the reason you selected above.

Name of Government Entity Issuing Quarantine or Isolation Order

If you are subject to a quarantine or isolation order from a government entity, please include the entity's name here.

Name of Advising Healthcare Provider

If you have been advised by a healthcare provider to self-quarantine, please include their name here.

Caring for an Individual with a Health Condition Related to COVID-19

COMPLETE THIS SECTION IF you are requesting leave to care for an individual with a health condition related to COVID 19. SKIP THIS SECTION IF you are requesting leave for your own health condition related to COVID 19 or requesting leave for child care related to COVID 19.

Leave Reason

Please select the reason below that best describes why you are requesting leave.

Select

Details

Please provide additional details for the reason you selected above.

Name of Individual

Please type the full name of the individual you are caring for with a health condition related to COVID 19.

Relationship to Individual

Below, please select your relationship to the individual you are caring for with a health condition related to COVID 19.

Select

Name of Government Entity Issuing Quarantine or Isolation Order

If you are caring for an individual who is subject to a quarantine or isolation order from a government entity, please include the entity's name here.

Name of Advising Healthcare Provider

If you are caring for an individual who has been advised by a healthcare provider to self-quarantine, please include their name here.

Child Care Need Related to COVID-19

COMPLETE THIS SECTION IF you are requesting leave for child care related to COVID 19. SKIP THIS SECTION IF you are requesting leave for your own health condition related to COVID 19 or requesting leave to care for an individual with a health condition related to COVID 19.

Leave Reason

Please select all of the criteria below that relate to why you are requesting leave.

Select

Name(s) of Child / Children

Please type the full name of the child / children you are providing care for due to COVID 19.

School(s) / Child Care Provider(s)

Please type the school(s) and/or child care provider(s) that are closed due to the public health emergency.

Available Options for Childcare

If requesting leave for childcare, please click on the statement below if it applies to your situation.

No other suitable person is available to care for the above mentioned child(ren).

Days Leave is Needed Each Week

Please share whether you require childcare leave everyday of the week OR whether you have childcare coverage for some days of the week and only need leave for specific days. If you selected "Child Care Need (Emergency Paid Sick Leave and/or Expanded Family Medical Leave)- Continuous" at the top of this form, your request will be to take leave for 5 days each week (full-time leave). If you selected "Child Care Need (Emergency Paid Sick Leave and/or Expanded Family Medical Leave)- Intermittent," please indicate which days each week you will need to take leave (part-time leave).

Select

Current Work Site

Please indicate the statement that best describes your current work site location / status below.*

I am currently required to work on site, but am unable to do so at this time.

Although I am entitled to telework, I am unable to do so at this time.

Statement of Acknowledgment

By clicking below, I acknowledge the following: (1) That the information contained in this form is true to the best of my knowledge; (2) that I believe I qualify for this leave based on my understanding of the requirements; (3) and I understand that misrepresentation of any information may result in the disqualification of this benefit, requirement to pay back monies, and disciplinary action, up to and including termination.*

Send me a copy of my responses

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