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Families First Coronavirus Response Act Request Form

Important Information Regarding your Families First Coronavirus Response Act (FFCRA) Request

The Families First Coronavirus Response Act (FFCRA or Act) requires certain employers to provide employees with paid sick leave or expanded family and medical leave for specified reasons related to COVID-19. The Department of Labor’s (Department) Wage and Hour Division (WHD) administers and enforces the new law’s paid leave requirements. These provisions will apply from the effective date through December 31, 2020. Please note, the university has voluntarily extended this benefit program through June 30, 2021.

Before applying, employees are required to review the information in the Family First Coronavirus Response Act Fact Sheet. Employees are also encouraged to review the information in the Families First Coronavirus Response Act. Additionally, if you are taking leave because you are experiencing symptoms related to COVID-19, you have tested positive, or you have been exposed to the virus, please complete the COVID-19 Screening Checklist to answer a series of screening questions if you have not already done so.

Acknowledgement Signature:*

By signing below I am certifying that I have read the Family First Coronavirus Response Act Fact Sheet. If I have any questions regarding the information contained in this document it is my responsibility to contact Human Resource Services.
 Sign using your S-signature eg. /Victor E. Huskie/ (forward slash on each side of your name).

   

Employee Information

Employee ID (eg. 00123456):

 
Search Employee ID
 

First Name:*

   

Last Name:*

   

Preferred Email:*

   

Preferred Phone:*

   

Employee Classification:*







 

Leave Requested

Reason For Leave:*







 

Name of Federal, State, or local entity that issued order:*

   

Name of health care provider that issued the advice:*

   

 Note – Medical information and documentation will need to be provided to Human Resource Services.

 

Please indicate additional information regarding the order:*


  

Name of health care provider that issued the advice:*

   

Name of Federal, State, or local entity that issued order:*

   

Please indicate the desired leave time:*



  

The name of the child being cared for:*

   

Name of the school, place of care, or child care provider that has closed or become unavailable:*

   

A statement from the employee that no other suitable person is available to care for the child:*

 
 

Standard Daily Work Schedule (Hours per Day)

Please indicate the total hours per day you are scheduled to work.

Monday:

   

Tuesday:

   

Wednesday:

   

Thursday:

   

Friday:

   

Saturday:

   

Sunday:

   

NIU Department:


 

Supervisor's Name:


Search NIU Directory  

Work Schedule 2

Monday:

   

Tuesday:

   

Wednesday:

   

Thursday:

   

Friday:

   

Saturday:

   

Sunday:

   

NIU Department:


 

Supervisor's Name:


Search NIU Directory  
  

Work Schedule 3

Monday:

   

Tuesday:

   

Wednesday:

   

Thursday:

   

Friday:

   

Saturday:

   

Sunday:

   

NIU Department:


 

Supervisor's Name:


Search NIU Directory  

Please indicate if you are a salaried or hourly employee:


  

Please select one of the following:*







 

NIU Department:


 

Supervisor's Name:


Search NIU Directory  

Please select one of the following:*







 

NIU Department:


 

Supervisor's Name:


Search NIU Directory  
  

Please select one of the following:*







 

NIU Department:


 

Supervisor's Name:


Search NIU Directory
 

Schedule for Hours Intended to Work

Please indicate the total hours per day that you plan to work while on leave.

Monday:

   

Tuesday:

   

Wednesday:

   

Thursday:

   

Friday:

   

Saturday:

   

Sunday:

   

Schedule for Hours Intended to be on Leave

Please indicate the total hours per day that you plan to be on leave and use benefit time.

Monday:

   

Tuesday:

   

Wednesday:

   

Thursday:

   

Friday:

   

Saturday:

   

Sunday:

   

Estimated Begin Date of Leave:*

 
 

Estimated End Date of Leave:*

 
 

Last Day Worked:*

 
 

Please provide a statement that you are unable to work (including work remotely) because of the reason for leave requested above:*

 
 

Please indicate if this form is being submitted by someone other than the employee requesting FFCRA Leave.


  

Leave Requested by (Include first and last name):*

 

Relationship:

   
Fields marked with * are required.

Disclosure:

By using this website you agree that your Name and/or ID fully, accurately and uniquely identifies you in our database. You furthermore agree that your submission of this form, via the "I Accept" button, shall constitute the execution of this document in exactly the same manner as if you had signed, by hand, a paper version of this agreement.
 
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