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) Both Please provide a statement to include the reason why the leave is neededDetails are critical to the approval of your request, a single word will not suffice. Please provide as much detail as possible.Please 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-19 2. I have been advised by a health care provider to self-quarantine related to COVID-19 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 the first reason or self-quarantine as described in the second reason 5. 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-19 6. I am experiencing another substantially-similar condition specified by the Secretary of Health and Human Services, in consultation with the Secretaries of Labor and Treasury When do you need your leave to start?*Date must be on or after April 1, 2020 MM slash DD slash YYYY When should it end?* 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 Child's Date of birth* MM slash DD slash YYYY 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. 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 salary No, I wish to save my PTO, I understand that I may only get 2/3 of my normal salary while on leave Additional information related to your leave request*Please provide any additional information that will help us approve and process your leave request. If information is placed here make sure to include as much detail as possible.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.