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Name: ______________________________________________________

Anticipated Begin Date: _______________________________________

Expected Return to Work Date: _________________________________

Employees may be entitled to expanded family medical leave in accordance with the Families First Coronavirus Response Act (FFCRA) if the employee satisfies eligibility standards.

Reason for Leave

Employees satisfying the standards below are eligible for 12 weeks* of leave. The first two weeks of the leave are unpaid unless the employee selects available options in the next box. The remaining 10 weeks of leave are paid at 2/3 of the employee’s regular compensation rate unless other options are selected on this form. Please select the applicable reason and follow the related instructions.

I,                                               , request family and medical leave because I am unable to work or telework because I need to care for my child(ren) under 18 because my child(ren)’s elementary or secondary school, childcare provider, or child’s place of care has been closed or is unavailable due to COVID-19. During this period of unavailability or closure, I represent that no other person will be providing care for my child during the period for which I am receiving expanded family medical leave benefits.

If the age of one or more of the children is between 14 and 18, the following special circumstances exist requiring me to care for the child during daylight hours:

Please attach notice or documentation related to the unavailability of the school, daycare, place of care or person providing care to the child. The District reserves the right to request confirmation regarding the nature of the closure or unavailability.

* An employee who qualifies for and utilizes the Emergency Paid Sick Leave provisions of the FFCRA, is entitled to an additional 10 weeks of Emergency FMLA.

Substitution of Paid Leave for the First Ten Days of Expanded Family Medical Leave

In accordance with the FFCRA, the first ten days of expanded family medical leave is unpaid, however you may be eligible to use Emergency Paid Sick Leave provided through the FFCRA to cover this period at 2/3 of full pay. In the event you have already used Emergency Paid Sick Leave, you are permitted to use available District-provided paid leave to cover this period at full pay. Please indicate if you would like to use paid leave during the first 10 days of your absence and how many hours you plan to use. Requested leave is subject to availability based on confirmation by the School District. If requesting Emergency Paid Sick Leave, please complete and submit an “Emergency Paid Sick Leave Request Form.”

___Emergency Sick Leave  ___Sick Leave  ___Personal Leave

Supplement 2/3 Pay with Accrued District Leave

Employees may choose to supplement the 2/3 pay provided through expanded family medical leave with accrued District leave to earn full compensation. Please indicate if you would like to use paid leave during your expanded family medical leave to supplement your 2/3 expanded family medical leave compensation. Requested leave is subject to availability based on confirmation by the District.

___Emergency Sick Leave  ___Sick Leave  ___Personal Leave

After completing the first ten days of expanded family medical leave, an employee may choose to take 10 weeks of continuous leave under expanded family medical leave for the reason indicated above. Continuous leave means the employee will not complete any District duties during this period but will be compensated based on the options selected above.

An employee may also choose to take 10 weeks of intermittent leave only with the District’s permission. Intermittent leave means an employee will complete some District duties on a modified schedule as approved by the employee’s supervisor. When using intermittent leave, the employee will receive full regular pay for hours worked and 2/3 of regular pay during periods on expanded family medical leave unless supplemented in a manner noted above.

I am requesting (choose one):

___ continuous leave

___ intermittent leave

If your need for leave is intermittent, please describe the requested schedule for your intermittent leave:                                                                                                                                                                                

I acknowledge that the above information is true to the best of my knowledge.

Signed: ________________________________________                                                        

Date: _______________________________                                                  


Note:  This type of emergency paid sick leave is only available through passage of the federal  Families First Coronavirus Response Act and will expire on December 31, 2020.  After that date, this exhibit should be removed from policy 409.2, as the benefit will no longer be available to employees.


Gilbert Community School District

Gilbert Community School District

103 Mathews Drive, Gilbert, Iowa 50105  |  (515) 232-3740