Editor's Note: This sample form is intended for use by employers who choose to provide employees with FFCRA-like leave. The tax credits for offering this leave expired on Sept. 30, 2021; however, employers may choose to continue providing leave voluntarily.
Request for Coronavirus-Related Paid Sick Leave
To request paid sick leave for absences related to the coronavirus, please complete the following request form and submit to your manager or the human resources department either prior to leave or as soon as possible after leave commences. Verbal notice will be accepted until a form can be completed.
Documentation supporting the need for leave must be included with this request.
Employee name (print clearly): _______________________________________________
Requested leave start date: ________________ End date: __________________
Number of hours of paid sick leave requested: ___________________________________
I am requesting this paid sick leave due to my inability to work (or telework) because (check the appropriate reason below):
Employee signature: ____________________________ Date: ____________________
Manager signature: _____________________________ Date: ____________________
HR Manager signature: __________________________ Date: ____________________