write a application for leave for hospital stuff due to lockdown
Answers
Explanation:
Employee Name (print clearly): ________________________________________________
Department: ______________________________
Manager: ________________________________
Requested Leave Start Date: ________________ End Date: __________________
The amount of emergency paid sick leave being requested is __________ hours.
[Optional: I wish to take intermittent leave for reason #5 below, during the following days and hours:]
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
I am requesting this emergency paid sick leave due to my inability to work (or telework) because (check the appropriate reason below):
❏ 1) I am subject to a federal, state, or local quarantine or isolation order related to COVID–19.
❏ 2) I have been advised by a health care provider to self-quarantine due to concerns related to COVID–19.
❏ 3) I am experiencing symptoms of COVID–19 and seeking a medical diagnosis.
❏ 4) I am caring for an individual who is subject to either number 1 or 2 above.
❏ 5) I am caring for my child whose primary or secondary school or place of care has been closed, or my childcare provider is unavailable due to COVID–19 precautions; and,
❏ I attest that no other suitable person is available to care for my child during the requested period of leave.
❏ I attest special circumstances exist requiring my need for leave to care for a child
ages 15-17.
❏ 6) I am experiencing another substantially similar condition specified by the secretary of health and human services.
I have attached documentation supporting my need for leave.
Employee Signature Date ___
Manager Signature Date ___
HR Department Rep. Signature Date