employee request for emergency paid sick ......if you did not have sufficient space above, please...

EMPLOYEE REQUEST FOR EMERGENCY PAID SICK LEAVE OR EMERGENCY FAMILY AND MEDICAL LEAVE FOR COVID-19 (CORONAVIRUS) RELATED

REASON AND SELF CERTIFICATION

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Employees requesting Emergency Paid Sick Leave and/or Emergency Family and Medical Leave must complete this form, collect proper documentation supporting the need for leave and return both to [ ]

as soon as practicable. Consult the Company’s Emergency Paid Sick Leave Policy and Emergency Family and Medical Leave Expansion Act Policy for more information regarding your entitlement to leave. Providing false information or

documentation shall constitute a violation of Company policy.

NAME: ____________________________________ Date of Request: _______________________

EMERGENCY PAID SICK LEAVE:

_____ I am unable to work or telework because I am subject to a federal, state or local quarantine

isolation order related to COVID-19. I attach documentation related to the order.

• Name of government entity issuing order:___________________________________

_____ I am unable to work or telework because I have been advised by a health care provider to

self-quarantine due to concerns related to COVID-19.

• Name of health care provider advising self-quarantine:_________________________

_____ I am unable to work or telework because I am experiencing COVID-19 symptoms and seeking a medical diagnosis.

• Name of health care provider from whom seeking diagnosis:____________________

_____ I am unable to work or telework because I am caring for an individual who is subject to a federal, state or local quarantine or isolation order related to COVID-19 or who has been

advised by a health-care provider to self-quarantine due to concerns related to COVID-19. I attach documentation related to the order.

• Name of individual to whom providing care:__________________________________

• Relationship to you of person to whom providing care:_________________________

• Name of government entity issuing order or health care provider advising self-quarantine:___________________________________________________________

_____ I am unable to work or telework because I am caring for my child whose school or child-care

provider is closed/unavailable due to concerns related to COVID-19. I attach documentation with this request demonstrating that the school or childcare provider is closed/unavailable.

• Name and age of child:_________________________________________________

• Name of school, place of care, or child care provider:__________________________

• Will any other suitable person be caring for the child during the period Emergency Paid Leave is requested?________________________________________________

• If the child is older than 14 and needs care during daylight hours, please explain the special circumstances that exist requiring you to provide care during those times:

_____ I am unable to work or telework because I am experiencing “any other substantially similar condition” specified by the U.S. Department of Health and Human Services.

LENGTH OF LEAVE: Begin: ___________ End: _____________



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ELECTION TO USE OTHER AVAILABLE LEAVE: You may elect to use any existing accrued, paid time off

before using Emergency Paid Sick Leave and/or you may use it to supplement your Emergency Paid Sick Leave benefit, to the extent such time is available for the reasons you have identified. Please contact

[ ] should you wish to utilize other accrued, paid time off. The ability to supplement the EPSL benefit with paid leave is at the Company’s discretion.

EMERGENCY FAMILY AND MEDICAL LEAVE (EFML)

_____ I am unable to work or telework because I am personally caring for my child because my child’s school, place of care, or childcare provider is closed/unavailable due to the COVID-19 public health emergency. I attach documentation with this request demonstrating that the

school or childcare provider is closed/unavailable.

• Name and age of child:_________________________________________________

• Name of school, place of care, or child care provider:__________________________

• Will any other suitable person be caring for the child during the period Emergency Paid Leave is requested?________________________________________________

• If the child is older than 14 and needs care during daylight hours, please explain the

special circumstances that exist requiring you to provide care during those times:

LENGTH OF LEAVE: Begin: ___________ End: _____________

ELECTION TO USE OTHER AVAILABLE LEAVE: The first ten days of EFML requested shall be unpaid. You may elect to use other accrued paid leave (such as PTO/Vacation) the first ten days of leave by electing

such below or you may use your Emergency Paid Sick Leave (“EPSL”) the first 10 days of your EFML. [ ] If you elect to use your EPSL benefit, you may utilize PTO/Vacation to supplement

it. [ ] The Company will require you to use any existing paid time off to supplement the EFML benefit you receive during the 10 weeks of paid EFML.

_____ I wish to use PTO/Vacation to the following unpaid portion of my EFML _________________. _____ I wish to use my EPSL benefit during the unpaid portion of my EFML.

_____ I wish to supplement my EPSL benefit during the first 10 days of my EFML using PTO/Vacation.

[If the employer is not going to require use of paid time off during the 10-week EFML benefit keep below]

_____ I wish to use PTO/Vacation to supplement the following days of my EFML benefit leave

____________________.

IF YOU DID NOT HAVE SUFFICIENT SPACE ABOVE, PLEASE FEEL FREE TO PROVIDE ANY ADDITIONAL RELEVANT INFORMATION IN THE SPACE BELOW



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BY SIGNING BELOW, I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I FURTHER UNDERSTAND THAT ANY FALSE STATEMENT MAY RESULT IN DISCIPLINARY ACTION, UP TO AND INCLUDING TERMINATION OF EMPLOYMENT.

__________________________________________________________________________ Print Full Name Signature Date

[Employers may wish to track leave designation on a separate form, similar to a traditional FMLA leave designation form. However, some employers may wish to insert an “Office Use Only” section here where they can track leave designation in one place.]

p. 1

XYZ COMPANY APPLICATION FOR EMPLOYMENT

[ ] Full time Position Desired:_____________________________________ [ ] Part time Date ___________________

WE ARE AN EQUAL OPPORTUNITY EMPLOYER APPLICANT’S STATEMENT

I understand that if I am hired, my employment will be for no definite period, regardless of the period of payment of my wages. I further understand that I am employed on an “at will” basis which means that I have the right to terminate my employment at any time with or without notice, and the Company has the same right. No one other than the President of the Company has authority to modify this relationship or make any agreement to the contrary. Any such modification or agreement must be in writing, signed by the President. I understand that the Company reserves the right to require me to submit to a drug test at any time and also reserves the right to require me to submit to an alcohol test and/or medical examination to the extent permitted by law. I understand that the Company may contact my previous employers and I authorize those employers to disclose to the Company all records and other information pertinent to my employment with them, whether favorable or unfavorable. I also authorize the Company to provide truthful information concerning my employment with it to my future prospective employers and I agree to hold it harmless for providing such information. By signing below, I certify that all of the information that I provide on this application and in any interview will be true, complete and accurate. I understand if I am employed and any such information is later found to be false, incomplete or misleading in any respect, I will be dismissed.

***AUTHORIZATION TO OBTAIN CONSUMER REPORTS***

IT HAS BEEN DISCLOSED TO ME THAT THE COMPANY MAY OBTAIN ONE OR MORE CONSUMER REPORTS ON ME FOR USE IN CONNECTION WITH MY APPLICATION OR FOR OTHER EMPLOYMENT-RELATED PURPOSES. THESE REPORTS MAY INCLUDE CREDIT BUREAU REPORTS, CRIMINAL RECORDS AND DRIVING RECORDS. I AUTHORIZE THE COMPANY OR PERSONS ACTING ON ITS BEHALF TO OBTAIN THESE REPORTS. _____________________________ ________________________________________________ Date Signature of Applicant

PERSONAL DATA Name____________________________________________________________ Social Security No._________________________ (Print) Last First Middle Present How long have Address__________________________________________________________ you lived there?___________________________ Street and Number City State Zip Years Months Previous How long did Address_________________________________________________________ you live there?_____________________________ Street and Number City State Zip Years Months Telephone No.____________________________________________________ Are you 18 years of age or older? [ ] Yes [ ] No How did you learn about our Company ?___________________________________________________________________________ Have you ever applied here or worked for this Company in the past? [ ] Yes [ ] No If yes, when?________________________ Do you have any friends or relatives working here? [ ] Yes [ ] No If yes, Name:_____________________________________________ Relationship:________________________________ Have you ever pled guilty or “no contest” to a crime or been convicted of a crime? [ ] Yes [ ] No Do you have any criminal charges pending? [ ] Yes [ ] No If Yes to either question, please give date and details of each: ___________________________________________________________________________________________________________ NOTE: Answering “Yes” to these questions will not constitute an automatic bar to employment. We will consider the type of

criminal offense(s), the date of the offense(s) and/or punishment(s) and the relationship between the offense(s) and the position for which you are applying. However, FAILURE TO FULLY DISCLOSE A CRIMINAL RECORD WILL DISQUALIFY YOU FROM EMPLOYMENT.

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RECORD OF PREVIOUS EMPLOYMENT Please list the names of your present or previous employers in chronological order with present or last employer listed first. Be sure to account for all periods of time including military service and any period of unemployment. If self-employed, give firm name and supply business references.

Present or Last Employer Employed From (mo/yr)

Pay Start $

Position Reason for Leaving

Address

City, State, Zip Code

To (mo/yr) Final $

Supervisor

Telephone

Previous Employer Employed From (mo/yr)

Pay Start $


Address


To (mo/yr) Final $

Supervisor

Telephone


Pay Start $


Address


To (mo/yr) Final $

Supervisor

Telephone


Pay Start $


Address


To (mo/yr) Final $

Supervisor

Telephone


Pay Start $


Address


To (mo/yr) Final $

Supervisor

Telephone

Have you ever been terminated or asked to resign from any job? [ ] Yes [ ] No. If Yes, please identify the employer and explain circumstances: _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ Please explain fully any gaps in your employment history: ___________________________________________________________________________ _________________________________________________________________________________________________________________________ May we contact your current employer? [ ] Yes [ ] No. If No, please explain: _______________________________________________________ _________________________________________________________________________________________________________________________

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EDUCATION

School Name Years Completed:

(Circle)

Diploma or

Degree

Describe Course of Study or Major

Describe Specialized Training, Experience, Skills, and Extra-

Curricular Activities

Elementary 4 5 6 7 8

High School

9 10 11 12

College

1 2 3 4

Graduate School 1 2 3 4

Trade or

Correspondence

Other

OTHER RELEVANT EXPERIENCE Describe other experience you have that is relevant to the job for which you are applying or list any job-related designations, certifications or courses completed that may be applicable to the position desired:

EMERGENCY INFORMATION In case of an accident or other emergency, who should we contact? Name_________________________________________________________________ Relationship______________________________________ Home address__________________________________________________________ Telephone:_______________________________________ Street City State Zip Work address___________________________________________________________ Telephone:_______________________________________ Street City State Zip

PERSONAL REFERENCES Please list persons who know you well – not previous employers or relatives.

Name Occupation Address

(Street, City and State) Telephone

Number

Number of Years Known

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I understand that this application will be considered active for a maximum of thirty (30) days from today’s date. If I have not been offered a position by then and I wish to be considered for employment after that time, I must reapply. I understand that my employment and continued employment is subject to the Company’s receipt, review and approval of all background checks. I certify that I am legally authorized to work in the United States of America. I certify that all of the information that I have provided on this application and in any interview is true, complete and accurate. I understand that if the Company later discovers that I failed to fully disclose my entire criminal record on this application, or that I failed to provide any material information requested in this application, I will be subject to immediate termination. _____________________________________________ __________________________________________________________ DATE SIGNATURE OF APPLICANT

Summary of Families First COVID-19 Response Act(Enacted March 18, 2020)

Emergency Paid Sick Leave Emergency Family and Medical Leave

Covered Employers

Private sector employers with fewer than 500 employees. Public agencies that employ 1 or more persons.

Private sector employers with fewer than 500 employees. Public employers regardless of size.

Leave for Must provide paid sick time “to the Any employee who has been employed for

What extent the employee is unable to work at least 30 days is entitled to:

Purposes (or telework) due to a need for leavebecause: 12 weeks of job protected leave when:

(1) The employee is subject to a federal, state or local quarantine or isolation

• “The employee is unable to work (or telework) due to the need for leave

order related to COVID-19. to care for the son or daughter under18 years of age of such employee if

(2) The employee has been advised the school or place of care has beenby a health care provider to self- closed, or the child care provider ofquarantine due to concerns related to COVID-19.

such son or daughter is unavailable, due to a public health emergency.”

(3) The employee is experiencing “Public Health Emergency” is definedsymptoms of COVID-19 and seeking a medical diagnosis.

to mean

• An emergency with respect to(4) The employee is caring for

an individual who is subject to an order or self-quarantine as described above.

COVID-19 declared by a Federal, State or local authority.

(5) The employee is caring for a son or daughter if school or child care is closed/unavailable.

(6) The employee is experiencing “any other substantially similar condition” specified by HHS (catch all).

Please note: This is a summary of preliminary information, so please contact your Fisher Phillips attorney for the most up to date information or with any questions.

fisherphillips.com

Please note: This is a summary of preliminary information, so please contact your Fisher Phillips attorney for the most up to date information or with any questions.

fisherphillips.com

Duration

Exemptions

Two weeks (80 hours for full-time employees and typical number of hours over two weeks for part-time employees).

ExemptionAn employer of an employee who is a health care provider or an emergency responder may elect to exclude such employee from the application of this section.

Secretary of Labor has the authority for good cause to issue regulations:

Emergency Paid Sick Leave

• To exclude certain health care providers and emergency responders from the definition of “eligible employee.”

• To exempt small businesses with fewer than 50 employees from leave to for a son or daughter if school or child care is closed/unavailable when the imposition of such requirement would jeopardize the viability of the business as a going concern.

• “As necessary” (catch-all).

Up to twelve weeks (the first 10 days of which are unpaid).

Emergency Family and Medical Leave

• The employee may elect to substitute any accrued paid leave (including emergency paid sick leave) during this 10-day period. The employer may not require the employee to substitute paid leave.

ExemptionAn employer of an employee who is a health care provider or an emergency responder may elect to exclude such employee from the application of this section.

Secretary of Labor has the authority for good cause to issue regulations:

• To exclude certain health care providers and emergency responders from the definition of “eligible employee”

• To exempt small businesses with fewer than 50 employees from the new law when the imposition of such requirements would jeopardize the viability of the business as a going concern


Emergency Paid Sick Leave Emergency Family and Medical Leave

Rate of Pay The higher of their regular rate of pay, the federal minimum wage, or the local minimum wage for qualifying reasons (1), (2) and (3), above.

• Capped at $511 per day and $5,110 in the aggregate per person.

Two-thirds the regular rate of pay for qualifying reasons (4), (5) and (6), above.

• Capped at $200 per day and$2,000 in the aggregateper person.

After 10 days, employees are compensated at 2/3 of their regular rate of pay.

• Capped at $200 per day and $10,000 in the aggregate per person.

Funding(Tax Credits)

Each quarter, private sector employers subject to the requirement are entitled to a tax credit equal to the amount of qualified sick leave wages paid by the employer (subject to the same caps as apply to the leave amount paid).

Each quarter, private sector employers subject to the requirement are entitled to a tax credit equal to the amount of qualified sick leave wages paid by the employer (subject to the same caps as apply to the leave amount paid).

Relationship

to Other Laws/Policies

• The bill also states that it shall not beconstrued in any way to diminish the rights of benefits that an employee is entitled to under any other federal, state or local law.

• There is nothing in the new law to suggest this gives an employee more than a total of 12 weeks of leave in a 12-month period under the FMLA.

• This enactment adds new qualifying reasons for leave under the FMLA, but does not expand the total of 12 weeks under the FMLA.

Effective Date and Sunset

No later than 15 days after enactment.

Sunsets December 31, 2020.

No later than 15 days after enactment.

Sunsets December 31, 2020.

This material is provided for informational purposes only. It is not intended to constitute legal advice, nor does it create a client lawyer relationship between Fisher & Phillips LLP and any recipient. Recipients should consult with counsel before taking any actions based on the information contained within this material.

Copyright ©March 20, 2020 Fisher Phillips LLP. All rights reserved.

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employee request for emergency paid sick ......if you did not have sufficient space above, please...

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