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.

Specific Leave Guidance

Frequently Asked Questions

To ensure timely processing of your request, please complete all fields.

EPSL and FMLA+ Request Form

First and Last Name (as it appears in SAP) *Name of Employee Submitting the Request
University Personnel ID Number *
University Email Address (@olemiss.edu) *
Phone Number *
Department *
Supervisor *
In the following sections please indicate the dates you are requesting a leave of absence and designate the type(s) of leave you are requesting and reason for the request.
I am requesting EPSL for the following reason. *
(1) Subject to a federal, state, or local quarantine or isolation order related to COVID-19(2) Under self-quarantine due to concerns related to COVID-19 based on the advice of a health care provider(3) Experiencing symptoms of COVID-19 and seeking a medical diagnosis(4) Caring for an individual who is subject to an order as described in (1) or who has been advised as described in (2)(5) caring for the employee’s child whose school or place of care is closed, or child care provider is unavailable, due to COVID-19 related reasons, or(5) Experiencing any other substantially similar condition specified by the Secretary of Health and Human Services in consultation with the Secretaries of Treasury and LaborN/A Not requesting EPSL
I am requesting FMLA+ because I am caring for a son or daughter, of any age, whose school or place of care has been closed, or whose childcare provider is unavailable, due to COVID-19 precautions.
Dependent Information If your requested leave is to care for an immediate family member, please complete the following section.
Dependent's Name *
Relationship to you: *
If the reason is related to the closure of a school or place of care, provide the name of the facility or childcare provider. School or facility name:
Requested Effective Date *
Please include the preferred method, email or current home address, to respond to your request. *
By submitting, I acknowledge this information is accurate to the best of my knowledge.

Verification

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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.

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.

EPSL and FMLA+ Request Form

Verification

Families First Coronavirus Response Act (FFCRA)
Leave of Absence Request