NY COVID-19 Sick Leave Request Form

Legal First Name *

Legal Last Name *

Do you live or work in the state of NY? *

Yes

No

I am requesting leave due to a mandatory or precautionary order of quarantine or isolation issued by the State, New York State Department of Health, local Board of Health, or other authorized government entity related to:
* 🛈

Me (employee)

My covered family member

Family member's relationship to you *

The isolation or quarantine is due to my or my family member's:
*

COVID-19 Symptoms

Positive COVID-19 test

Close contact with a COVID-19 positive individual

Date(s) leave was/will be taken (MM/DD/YYYY). *

Name of the governmental entity ordering quarantine or the name of the health care provider advising self-quarantine: *

Employees are eligible for this leave for up to 3 occurrences of being under a precautionary or mandatory order of quarantine or isolation for themselves or qualified family member. Please indicate what number occurrence your request is related to: *

1st

2nd (positive test required)

3rd (positive test required)

I certify the following: *

I was UNABLE to work my entire commitment remotely on the dates noted above due to my NY COVID-19 Leave reason

I was ABLE to work my entire commitment remotely on the dates noted above

Employee signature *

clear

Form completion Date: * +