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COVID 19 Leave Request Form

This COVID-19 leave request form allows employees to request leave related to the pandemic. Employees can request leave if they are quarantined, have COVID-19 or suspect they have it, need to care for someone with COVID-19, or require leave to care for a child due to school/daycare closure. The form collects the employee and supervisor's details, reason for leave, dates, availability for telework, and requires supporting documentation and a signature.

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Santosh KAR
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143 views2 pages

COVID 19 Leave Request Form

This COVID-19 leave request form allows employees to request leave related to the pandemic. Employees can request leave if they are quarantined, have COVID-19 or suspect they have it, need to care for someone with COVID-19, or require leave to care for a child due to school/daycare closure. The form collects the employee and supervisor's details, reason for leave, dates, availability for telework, and requires supporting documentation and a signature.

Uploaded by

Santosh KAR
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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COVID-19 LEAVE REQUEST FORM

INSTRUCTIONS: Employees requesting leave related to COVID-19 should complete


this form ONLY if you are requesting the leave due to one of the reasons listed below.
Requests for any other reason will follow standard procedures. Return this form via
email to _________________ or via fax to ________________.

EMPLOYEE DETAILS:
Name: ________________________________________________________________
Mailing Address: ________________________________________________________
Email: ________________________________________________________________
Home/Cell Phone: ______________________________________________________
Supervisor: ____________________________________________________________

REQUEST DETAILS:
□ Quarantined or isolated by order of State/Federal/Local official or medical doctor
□ Confirmed case of COVID-19
□ Suspected case of COVID-19, and seeking a medical diagnosis
□ To care for individual with a confirmed case of COVID-19 or one who is subject
to a quarantine/isolation order by order of State/Federal/Local official
□ Parent □ Spouse □ Child □ Other
If you checked “Other,” please explain below:
_______________________________________________________________
_______________________________________________________________

□ To provide care for a child due to COVID-19 school closure or childcare


unavailability

TELEWORK
□ I am available to telework if such work is offered.
□ I am not available to telework if such work is offered.

1
DATES FOR REQUESTED LEAVE

___________________, 2020 through ___________________, 2020.

SUPPORTING DOCUMENTATION ATTACHED:

□ Copy of State/Federal/Local quarantine or isolation order related to COVID-19


□ Documentation from healthcare provider advising self-quarantine for COVID-19
□ Documentation from healthcare provider on seeking diagnosis for suspected
COVID-19
□ Documentation from healthcare provider advising self-quarantine for COVID-19
for individual within your care
□ Documentation of school closing or childcare unavailability

Employer reserves the right to request additional documentation at any time.

EMPLOYEE ACKNOWLEDGMENT
I understand that completion of this form constitutes a request only and is subject to
approval by employer. I certify that the information contained on this form is true and
correct to the best of my knowledge. I authorize ______________________ to obtain
and verify any necessary information regarding my request. I understand that providing
false information may result in corrective action up to, and including, termination of my
employment.
_____________________________________ __________________________
EMPLOYEE SIGNATURE DATE

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