EPSL Form Massachusetts COVID-19 Temporary Emergency Paid Sick Leave Request Form By law, employees must submit a written request to their employer to take Massachusetts COVID-19 Temporary Emergency Paid Sick Leave (COVID-19 Sick Leave). Complete and submit this form to your HR department, along with written supporting documentation, before taking leave or as soon as practicable. You must also follow all other standard notification procedures with respect to your supervisor or manager as applicable.Name(Required)Email(Required) Department/Position(Required)Leave Start Date/Time(Required)Leave End Date/Time(Required)I need to: self-isolate and care for myself because I have been diagnosed with COVID-19 get a medical diagnosis, care, or treatment for COVID-19 symptoms; or get or recover from a COVID-19 immunization I need to care for a family member who: must self-isolate due to a COVID-19 diagnosis; or needs medical diagnosis, care, or treatment for COVID-19 symptoms. needs to obtain or recover from a COVID-19 immunization. I am subject to a quarantine order or similar determination regarding the employee by a local, state, or federal public official, a health authority having jurisdiction, or a health care provider. Name of governmental entity or health care provider ordering or advising self-quarantine:I need to care for a family member due to a quarantine order or similar determination regarding the family member by a local, state, or federal public official, a health authority having jurisdiction, the family member’s employer, or a health care provider. Name of governmental entity or health care provider ordering or advising self-quarantine:Name of person subject to quarantine, and relationship to person (such as spouse, parent, etc.):In support of this request, I am attaching the following documentation: If diagnosed with COVID-19 - documentation of positive results. If recovering from a Covid-19 immunization - Proof of immunization Quarantine - Provide proof of an ordered quarantine If you have any questions relative to eligibility and/or leave amounts permitted under the EPSL Act, please view the attached guidance or contact Human Resources.Signature(Required)Date MM slash DD slash YYYY Make sure to provide any relevant supporting written documentation, along with this completed and signed written notice, to your HR office. File(Required)Max. file size: 50 MB. FOR HR USE ONLY:
