Families First Coronavirus Response Act (FFCRA)
Leave of Absence Request
This benefit was only available through December 31, 2020. Please do not complete the request form for absences on/after January 1, 2021.
Employees requesting Emergency Paid Sick Leave (EPSL) or Expanded Family and Medical Leave (FMLA+) in accordance with the FFCRA must complete the form below and submit to Human Resources for review. You may be required to provide supporting documentation in accordance with EPSL, FMLA+, and/or FFCRA.
It is the employee’s responsibility to notify their immediate supervisor or department head that a request for leave of absence has been submitted to Human Resources. A letter of approval or declination will be provided to you and a copy provided to your department head.
To ensure timely processing of your request, please complete all fields.
If your situation doesn’t meet the criteria for these two leave programs, however, you still have concerns regarding a potential underlying health condition, visit our Family and Medical Leave Act site.