Employee Certification of Need for Emergency Paid Sick Leave (EPSL) for COVID-19 Form Header Image

Employee Certification of Need

for Emergency Paid Sick Leave (EPSL) for COVID-19

Applicable to Faculty through 12/17/2021 per AFT MOU

Please find in this section information regarding Emergency Paid Sick Leave and Expanded Family and Medical Leave under the Families First Coronavirus Response Act (FFCRA).

FFCRA Leaves Information

2021 COVID-19 Supplemental Paid Sick Leave

Emergency Paid Sick Leave and Expanded Family Medical Leave Guidelines

Once the Emergency Paid Sick Leave (EPSL) for COVID-19 form is completed, a copy of this form will be sent to Human Resources. If your request is approved by Human Resources, a copy of your approved form will be emailed to you and your supervisor. If at any time you need assistance completing this form, please contact, Ingrid Melgoza melgozai@smccd.edu, in Human Resources.

To begin the form, please click Start below:

Employee Certification of Need for Emergency Paid Sick Leave (EPSL) for COVID-19

Name
Classification
Campus
NOTE: Supervisor will only be notified if the EPSL leave is approved
I certify that I am unable to work (or work remotely) due to the following reason
I am requesting EPSL (2 week maximum) to begin on this date
I understand that if my circumstances change, I must immediately inform my supervisor and the Office of Human Resources and I may be directed to report back to work (or work remotely).
And end on this date
I understand that if my circumstances change, I must immediately inform my supervisor and the Office of Human Resources and I may be directed to report back to work (or work remotely).
I have attached documentation supporting the reason: (e.g. medical certification, e-mail required self-quarantine, copy of the COVID-19 vaccination record card, letter of child care closure, letter/website notice of school closure)
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Human Resources may request employee to provide additional documentation for the use of this EPSL certification. Documents will only be reviewed by Human Resources.
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