FFCRA Reporting

Emergency Paid Sick Leave under FFCRA Request

Please complete the form below if you are not approved/or unable to work remotely. FFCRA allows for employees to take up to 10 consecutive workdays due to CoVID-19. FFCRA can be used only ONCE and if you are exposed or tested positive again for CoVID-19 your sick days will be used. For additional information visit https://www.dol.gov/agencies/whd/pandemic/ffcra-employer-paid-leave
Have you file for FFCRA in the past? *

Yes No
Name *

Last Name First Name
Employee ID *
Email *
example@example.com
Phone Number *
Please enter a valid phone number.
Position/Title *
Campus/Department *
Principal/Supervisor *
Start Date of FFCRA Leave *

Month Day Year
Date
Reason for FFCRA *

I have been required to quarantine due to concerns related to COVID-19. I am caring for a child whose school or place of care is closed due to COVID-19 related reasons (temporary school closure and/or school exposure), and job cannot be performed remotely/virtually.
FFCRA Proof

proof of school closure or exposure notice, doctor's note, CoVID results, etc.
Cancel of
Should be Empty:

Emergency Paid Sick Leave under FFCRA Request