FMLA Request Form Employee Name* First Last Your Email Address*Your email address will be used to send you a confirmation of your submission for proof if needed. Is this request for 80 hours of paid sick time (PST) and/or Paid Family Leave (PFML)?If you wish to request both please select "Both" below.Paid Sick Time (PST)Paid Family Leave (PFML)BothPlease provide a statement to include the reason why the leave is neededPlease select a qualifying reason*The following reasons are considered qualifying for requesting leave, please check the appropriate reason.1. I am subject to a Federal, State, or local quarantine or isolation order related to COVID-192. I have been advised by a health care provider to self-quarantine related to COVID-193. I am experiencing COVID-19 symptoms and seeking a medical diagnosis4. I am caring for an individual subject to an order described in the first reason or self-quarantine as described in the second reason5. I am caring for a child whose school or place of care is closed (or child care provider is unavailable) for reasons related to COVID-196. I am experiencing another substantially-similar condition specified by the Secretary of Health and Human Services, in consultation with the Secretaries of Labor and TreasuryWhen do you need your leave to start?*Date must be on or after April 1, 2020 Date Format: MM slash DD slash YYYY When should it end?* Date Format: MM slash DD slash YYYY Name of dependent/child*If you are caring for more than a single dependent or child just list one of them. First Last Name of provider/school*Phone number of provider/school*Date provider or school closed for reasons related to COVID-19*If we do not have documentation on file, you may be asked to provide documentation in the form of a notice or email from your school or provider. Date Format: MM slash DD slash YYYY Do you wish to use paid sick leave (PST) or PTO for your first 10 days?*Paid Sick Leave (this is paid time offered in addition to your PTO)PTO (you may choose to use PTO if you think you may use paid sick leave for a COVID-19 related reason at a later time and before 12/31/2020)Use PTO for the remaining third of your salary?*If the selected reason and your current situation will only provide you with 2/3 of your salary, do you wish to have PTO automatically applied to the remaining third so you don't see a reduction in pay?Yes, automatically apply my PTO to remaining third of my salaryNo, I wish to save my PTO, I understand that I may only get 2/3 of my normal salary while on leaveAdditional information related to your leave request*Please provide any additional information that will help us approve and process your leave request.Please Note If this is a request for PFML, you may be required to provide additional documentation. You will be notified by email upon approval of your paid sick leave/PFML request.