COVID-19 Leave Request

As of March 31, 2021, the Emergency Paid Sick Leave provision under the Families First Coronavirus Response Act has expired. However, employees who are exposed to COVID-19 or who test positive must follow the mandatory quarantine orders below as provided by the CDC. Employees subject to quarantine may choose to use any of their own accrued leave. Who must quarantine? People who have been in close contact with someone who has COVID-19—excluding people who have had COVID-19 within the past 3 months or who are fully vaccinated MUST quarantine. What counts as close contact? Any combination of 1 or more of the following conditions: 1. You were within 6 feet of someone who has COVID-19 for a total of 15 minutes or more 2. You provided care at home to someone who is sick with COVID-19 3. You had direct physical contact with the person (hugged or kissed them) 4. You shared eating or drinking utensils 5. They sneezed, coughed, or somehow got respiratory droplets on you What are my options to reduce quarantine after exposure to COVID-19? 1. After day 10 without testing 2. After day 7 after receiving a negative test result (test must occur on day 5 or later)

Employee Number*

Employee Name*

Format: Last Name, First Name

Employee Email*

This email will be the primary way we will communicate with you regarding your leave request. Please ensure to check it regularly for communications.

Employee Phone Number*

Supervisor Email*

Timekeeper Email

Include if different than supervisor's email

Leave Reason for COVID-19 Leave*

1- I am subject to Federal, State or local quarantine or isolation order related to COVID-19

2 - I have been advised by a health care provider to self-quarantine related to COVID-19

3 - I am experiencing COVID-19 symptoms and I am seeking a medical diagnosis

4 - I am caring for a individual who is subject to Federal, State or local quarantine or isolation or has been advised by a health care provider to self-quarantine related to COVID-19

6 - is experiencing any other substantially-similar condition specified by the Secretary of Health and Human Services, in consultation with the Secretaries of Labor and Treasury

File Upload*

*For leave reasons 1-4 or 6, attach documentation from medical provider or issuer of the relevant order to support the request, or if such information is not immediately available, provide the name of the medical care provider or issuer of the order or quarantine notice.

Drag and drop files here or

Anticipated Begin Date of Leave*

Expected Return to Work Date

If unknown, leave blank.

Additional Information

Please provide us any additional information we need to know about this request.

Employee Acknowledgement*

By typing my name below, I certify that the information above is accurate and complete. I certify I have read, understand, and agree to the Madison County Temporary Families First Coronavirus Response Act (FFCRA) Policy. I further understand that I must report to work on the scheduled return date indicated above or I must contact Human Resources regarding my need for continued absence from work beyond the scheduled return date indicated above. I understand it is my responsibility to communicate with my supervisor, timekeeper, and Department Head regarding my leave request.

Today's Date*

Send me a copy of my responses

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