CALIFORNIA 2022 COVID-19 SUPPLEMENTAL PAID SICK LEAVE REQUEST FORM

The state of California has passed a new 2022 version of COVID-19 Supplemental Paid Sick Leave (SPSL) effective February 19, 2022, and apply retroactively back to January 1, 2022, and is in effect until December 31, 2022.

To request qualified paid sick leave for absences related to COVID-19 and if you meet one of the requirements below, please complete this request form and submit to human resources either prior to leave or as soon as possible after leave commences. Verbal notice will be accepted until a form can be completed.

Your name*

First NameLast Name

Your email address*

Enter the email address used by Scoot to contact you

Enter your start date with Scoot Education*

Check your offer letter for start date

Requested leave start date*

Date

Requested leave end date*

Date

Please note: the number of supplemental paid sick leave hours you're eligible for will be based on hours worked in the last 6 months, in accordance with California law.

Number of hours of paid sick leave requested:

COVID-19 sick leave may only be claimed if you meet one or more of the following criteria checkmark as applicable if you unable to work or telework:

Category 1:

Vaccine-Related: You are attending a vaccine or booster appointment for yourself or a family member* or cannot work or telework due to receiving the vaccine, related symptoms, or are caring for a family member with vaccine-related symptoms. (Limited to 24 hours or 3 days of leave for each vaccination or booster appointment and any consequent side effects, unless a health care provider verifies that more recovery time is needed.)

Attending an appointment for yourself to receive a COVID-19 vaccine or vaccine boosterAttending an appointment for family member to receive a COVID-19 vaccine or boosterExperiencing symptoms from COVID-19 vaccine or vaccine boosterCaring for a family member that is experiencing symptoms from COVID-19 vaccine or vaccine booster

Caring for Yourself: You are subject to a quarantine or isolation period related to COVID-19 as defined by an order or guidance of the California Department of Public Health, the federal Centers for Disease Control and Prevention, or a local public health officer with jurisdiction over the workplace; or have been advised by a healthcare provider to quarantine; or is experiencing COVID-19 symptoms and seeking a medical diagnosis.

Leave due to government-issued quarantine or isolation orderLeave due to health-care provider’s advice to quarantineExperiencing symptoms and seeking medical diagnosis by a health-care provider

Caring for a Family Member*: You are caring for a family member who is subject to a COVID-19 quarantine or isolation period or have been advised by a healthcare provider to quarantine due to COVID-19, or are caring for a child whose school or place of care is closed or unavailable due to COVID-19 on the premises.

*A family member includes a child, parent, spouse, registered domestic partner, grandparent, grandchild, or sibling.

Caring for a family member subject to quarantine/isolateCaring for a child whose school or place of care is closed

You have tested positive for COVID-19You are caring for a family member* who has tested positive for COVID-19

You must select an option from either Category 1 or Category 2 to submit this form.

By claiming this 2022 COVID-19 sick paid sick leave, you are attesting that you meet one or more of the criteria above and must select one of the boxes on the form. Additional information may be required or requested, depending upon the basis for leave and whether the employer needs additional information or documentation in connection with tax or reporting requirements. I certify under penalty of perjury under the laws of the State of California that I have accurately and truthfully answered the questions above and understand falsification of any information given may lead to disciplinary action up to and including termination.

Signature*