Request for Emergency Leave under the Families First Coronavirus Response Act (FFCRA)

Request for Emergency Leave

The Families First Coronavirus Response Act (FFCRA or Act) requires certain employers, including R&K Excavation, to provide their employees with paid sick leave and expanded family and medical leave for specified reasons related to COVID-19. These provisions will apply from April 1, 2020 through December 31, 2020.

► PAID LEAVE ENTITLEMENTS

Generally, employers covered under the Act must provide employees:

Up to two weeks (80 hours, or a part-time employee’s two-week equivalent) of paid sick leave based on the higher of their regular rate of pay, or the applicable state or Federal minimum wage, paid at:

100% for qualifying reasons #1-3 below, up to $511 daily and $5,110total;
2/3 for qualifying reasons #4 and 6 below, up to $200 daily and $2,000 total; and
Up to 12 weeks of paid sick leave and expanded family and medical leave paid at 2/3 for qualifying reason #5 below for up to $200 daily and $12,000 total.

A part-time employee is eligible for leave for the number of hours that the employee is normally scheduled to work over that period.

► ELIGIBLE EMPLOYEES

In general, employees of private sector employers with fewer than 500 employees, and certain public sector employers, are eligible for up to two weeks of fully or partially paid sick leave for COVID-19 related reasons (see below).Employees who have been employed for at least 30 days prior to their leave request may be eligible for up to an additional 10 weeks of partially paid expanded family and medical leave for reason #5 below.

Employee Name

This is a (choose one):

Requested leave start date

Expected return to work date

I am requesting emergency paid sick leave for the following reason: I am requesting emergency paid sick leave for the following reason: 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 related to COVID-19. (submit documentation from provider advising self-quarantine to mpersch@rkexc.com). 3. I am experiencing COVID-19 symptoms and seeking a medical diagnosis. 4. I am caring for an individual subject to an order described in (1) or self-quarantine related to COVID-19. 5. I am caring for a child under age 18 whose school or place of care is closed, or childcare provider is unavailable due to COVID-19 reasons, and no other person will be providing care for the child(ren) during my normal work time. (Submit announcement or other documentation of closure or provider unavailability to mpersch@rkexc.com.) 6. I am experiencing any other substantially-similar condition specified by the U.S. Department of Health and Human Services.

Name of government entity issuing order

Name and phone number of provider

Date of medical visit

Date results expected

Name for whom you are caring

Relationship

Age of the individual for whom you are caring

Pursuant to the FFCRA, the first 10 days of your FMLA leave is unpaid, however you may be eligible for emergency paid sick leave provided through the FFCRA, in which case this sick leave will be paid. Pursuant to the FFCRA, the first 10 days of your FMLA leave is unpaid, however you may be eligible for emergency paid sick leave provided through the FFCRA, in which case this sick leave will be paid. I certify that the above information is accurate and complete, and I have submitted or turned in the required documentation. I attest and agree that I am unable to work including telework and will not work for another Contributing Employer during the time I am on emergency leave.

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