Emergency Family Medical Leave (EFMLEA) Request Form

  • The Families First Corona Virus Relief Act (FFCRA) was enacted on March 18, 2020 and contains two emergency paid leave programs to support employees during the coronavirus pandemic. Division C of the FFCRA, “The Emergency Family and Medical Leave Expansion Act” (EFMLEA), amends Title I of the Family and Medical Leave Act, 29 U.S.C. 2601 et seq. (FMLA), and permits employees to take up to twelve weeks of expanded family and medical leave, ten of which are paid, if they are unable to work (or telework) due to caring for their child when a school or place of care has been closed, or when a regular child care provider is unavailable due to a public health emergency with respect to COVID-19.

    Employees must qualify and provide requested documentation as defined in the law and expanded upon by the Dept. of Labor and IRS in order to receive paid leave.

    Leave is unpaid for the first 10 days; however, employees may elect to use the paid leave provided under the Emergency Paid Sick Leave Act (EPSLA) for the first 2 weeks. Apply for EPSLA.

    >>MORE INFORMATION on the EFMLEA paid leave policy

    Please complete the following form to apply for EFMLEA leave:

  • Part I. Employee Information

  • Part II. Leave Dates

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Part III. Reason For Leave

  • Select all that apply
  • Definition of "Child"

    "Child" means a biological, adopted or foster child, a stepchild, a legal ward, or a child of a person standing in loco parentis, who is under 18 years of age or 18 or older and incapable of self-care because of a mental or physical disability

  • click + to add additional children
    Name of childAge 
  • Definition of "Childcare Provider" or "School"

    "Child care provider" means a provider who receives compensation for providing child care services on a regular basis, including: • A center-based child care provider. • A group home child care provider. • A family child care provider (one individual who provides child care services for fewer than 24 hours per day, as the sole caregiver, and in a private residence). • Other licensed provider of childcare services for compensation. • A childcare provider that is 18 years of age or older who provides child care services to children who are either the grandchild, great grandchild, sibling (if such provider lives in a separate residence), niece or nephew of such provider, at the direction of the parent.

    "School" means an elementary or secondary school.

  • click + to add additional schools or providers
    NameDate of closureDate of reopening if known 
  • Documentation could be a notice posted on a government, school, or day care website or an email or written note from an employee or official of the school, place of care, or child care provider.
  • Part IV. Documentation

  • Documents must be in pdf, doc, or docx formats. Images may be jpg, gif, or png. Files may not exceed 64 MB.
    Drop files here or
    Accepted file types: jpg, gif, png, pdf, doc, docx.
    • Part V. Acknowledgements

    • Part VI. Signature

    • Date Format: MM slash DD slash YYYY
    • Please type in your full name