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Emergency Paid Sick Leave

Emergency Paid Sick Leave Application Form

The Emergency Paid Sick Leave has been extended from January 1, 2021 to May 21, 2021. Employees that need to apply for this leave must complete this application form electronically or request a hard copy at [email protected]. Human Resources if approved will notify employees that submit this application form. Employees must submit the appropriate documentation regarding their leave request with this application if required. Please contact Human Resources with any further questions or concerns by emailing [email protected].

Please complete the form below. Required fields marked with an asterisk *

Permiso de ausencia pagada por enfermedad se extendió del 1 de enero al 21 de mayo del 2021. Empleados que deseen aplicar para este programa deberán llenar esta solicitud electrónica o pedir una copia a [email protected]. Empleados que entregan esta solicitud serán notificados por recursos humanos de ser aprobada. Empleados deberán entregar la documentación apropiada para su petición con esta solicitud. Favor de contactar a recursos humanos para cualquier duda o pregunta al correo electrónico [email protected]

Por favor complete la siguiente forma. Los espacios marcados con * son necesarios.

Date/Fecha*

Answer Required

Employee Information/Información de Empleado

First Name/Nombre*

Answer Required

Last Name/Apellido(s)*

Answer Required

Employee ID/Número de Empleado

Answer Required

Email/Correo Electronico*

Answer Required

Phone/Teléfono*

Number Required

Position/Posición*

Answer Required

Site/Escuela o Departamento*

Answer Required

Leave Start Date/Primer Día Laboral Fuera*

Answer Required

Leave Ending Date/Ultimo Día Laboral Fuera*

Answer Required

Please select the reason for your request. Employees must attach medical notes for request #1-4/Por favor seleccione la razon de su solicitud. Razones #1-4 requieren que adjunte justificante/carta medica.

Answer Required

1.- Employee is subject to Federal, State, or local quarantine or isolation order related to COVID-19 / Está sujeto a orden de cuarentena o aislamiento Federal, Estatal, o local relacionada al COVID-19

2.- Employee has been advised by a health care provider to self-quarantine related to COVID-19 / Ha sido instruido por un proveedor de salud que se ponga en auto-cuarentena por COVID-19

3.- Employee is experiencing COVID-19 symptoms and is seeking a medical diagnosis / Está experimentando síntomas de COVID-19 y está solicitando diagnóstico médico

4.- Employee is caring for an individual subject to an order described in (1) or self-quarantine as described in (2) / Está cuidando a una persona sujeta a una orden descrita en (1) o en auto-cuarentena descrita en (2)

Upload doctor's letter / Adjunte Justificante-carta médica

Answer Required

Choose a file or drag it here.

Please list the name and your relationship of the individual(s) being cared if you selected (4) as reason for your request. Por favor escriba los nombres y la relación de la(s) personas bajo su cuidado si seleccionó el 4 como razón por su solicitud.

Answer Required

Type of Leave Requesting*

Answer Required

Emergency Paid Sick Leave (Reasons 1 through 3) - Paid at 100% (2 weeks maximum leave allowed) Pago de emergencia por enfermedad (razones 1 al 3) - Se pagará al 100% de salario (máximo 2 semanas de ausencia permitida)

Emergency Paid Sick Leave (Reasons 4 ) - Paid at 2/3 of Pay (2 weeks maximum leave allowed) Pago de emergencia por enfermedad (Razón 4) - Se pagará 2/3 de salario (máximo 2 semanas de ausencia permitida)

Question

Answer Required

I wish to utilize my employee district leave (i.e. annual leave, paid sick leave, vacation) to supplement the 2/3 pay to earn full compensation. Deseo utilizar mis horas acumuladas (horas anuales, horas de enfermedad, horas de vacaciones) para suplementar el 2/3 de paga y recibir salario al 100%.

I do not wish to utilize my employee district leave (i.e. annual leave, paid sick leave, vacation) to supplement the 2/3 pay to earn full compensation. No deseo utilizar mis horas acumuladas (horas anuales, horas de enfermedad, horas de vacaciones) para suplementar el 2/3 de paga y recibir salario al 100%.

By typing my name below, I am certifying that the information provided is accurate and complete and that all needed documentation has been submitted to Human Resources. Al escribir mi nombre aqui, certifico que la information anterior es correcta y completa y que toda la documentacion necesaria ha sido entregada a Recursos Humanos.

Answer Required

Confirmation Email

Email Required