Families First Act Leave Application Form

The Families First Coronavirus Response Act became effective on April 1, 2020 through December 31, 2020. Employees that would like to apply for this leave must complete this application form electronically or request a hard copy at [email protected]. Employees that submit this application form will be notified by Human Resources if approved. 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 *

La Ley Familias Primero de Respuesta al CoronaVirus aplicara desde abril 1 hasta diciembre 31 del 2020. Empleados que deseen aplicar para esta ley deberan llenar esta solicitud electronica o pedir una copia a [email protected]. Empleados que entregan esta solicitud seran notificados por recursos humanos de ser aprovada. Empleados deberan entregar la documentacion apropriada para su peticion con esta solicitud. Favor de contactar a recursos humananos para cualquier duda o pregunta al correo electronico [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 #1-5/Por favor seleccione la razon de su solicitud. Razones #1-5 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)

5.- Employee is experiencing any other substantially-similar condition specified by the U.S. Department of Health and Human Services / Está experimentando otras condiciones sustancialmente similares a las especificadas por el Secretario de Salud y Servicios Humanos.

Upload doctor's letter / Adjunte Justificante-carta médica

Answer Required

Choose a file or drag it here.

Please list the name of the individual(s) being cared if you selected (4) or (5) as reasons for your request. Por favor escriba los nombres de la(s) personas bajo su cuidado si seleccionó el 4 o 5 como razón por su solicitud.

Answer Required

Question

Answer Required

6.- Employee is caring for his or her child whose school is closed due to COVID-19 related reasons / Está cuidando a un hijo cuya escuela está cerrado por razones de COVID-19

Please list the name(s), age(s), and school(s) of your child(ren) if you selected (6) as the reason for your request.(must be under 18 years of age) Por favor escriba nombre(s), edad (es) y escuela(s) de su hijo(s) si selecciono opción 6 como la razón de su solicitud. (debe ser menor de 18 años)

Answer Required

Question

Answer Required

7.- Employee is caring for his or her child whose place of care is closed due to COVID-19 related reasons / Está cuidando a un hijo cuyo lugar de cuidado (o cuidados infantiles no están disponibles) esta cerrado por razones de COVID-19

Please upload a statement that your daycare/babysitter is not available due to COVID-19 for non-school aged children only / Por favor adjunte un escrito especificando que cuidados infantiles/niñera no están disponible por motivos de COVID-19 para sus hijos que aún no tienen la edad para entrar a la escuela.

Answer Required

Choose a file or drag it here.

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 and 5) - Paid at 2/3 of Pay (2 weeks maximum leave allowed) Pago de emergencia por enfermedad (razones 4 y 5) - Se pagará 2/3 de salario (máximo 2 semanas de ausencia permitida)

Emergency Paid Sick Leave and Emergency Family Medical Leave (Reason 6 and 7) - Paid at 2/3 of Pay (12 weeks maximum leave allowed) Pago de emergencia por enfermedad y ausencia médica de emegencia familiar (razón 6 y 7) - se pagará 2/3 de salario (máximo 12 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

Please fix the highlighted areas below before submitting.

Families First Act Leave Application Form