2. Name*
3. Date
5. I am requesting to use Paid SICK leave under the Families First Coronavirus Response Act (HR 6201) for one of the following reasons (please check one):
7. 1.

   1. I am subject to a federal, state, or local quarantine or isolation order due to COVID-19.
9. 2.

   1. I have been advised by a health care provider to self-quarantine due to concerns related to COVID-19.
11. 3.

    1. I am experiencing symptoms of COVID-19 and seeking a medical diagnosis.
13. 4.

    1. I am caring for an individual who is subject to an order as provided in (1) or has been advised as per (2).
15. 5.

    1. I am caring for a son or daughter because the school or place of care for the child has been closed, or the childcare provider is unavailable, due to COVID-19 precautions.
17. 6.

    1. I am experiencing any other substantially similar condition specified by the Secretary of Health and Human Services in consultation with the Secretary of Treasury and the Secretary of Labor.

    You are eligible for 80 hours of paid sick time at 2/3 of your regular rate of pay without using your accruals.**
19. 7.

    1. I am sick and unable to perform my regular job responsibilities and I DO NOT meet any of the conditions set forth in 1-6 above. You must provide a doctor’s note.
21. 8.

    1. I do not meet any of the requirements above, but would like to take a leave of absence from work because I do not feel safe at work because of the coronavirus.
23. The quarantine period is scheduled to end:*
    You are eligible for 80 hours of Paid sick at your regular rate of pay without using your accruals. *
25. I Have OR Have Not been in contact with a physician?*
    You are eligible for 80 hours of Paid sick at your regular rate of pay without using your accruals.*
27. The quarantine will end:*
    You are eligible for 80 hours of paid sick time at 2/3 of your regular rate of pay without using your accruals. **
29. The anticipated need to care for my son or daughter will end:
    You are eligible for 80 hours of paid sick time at 2/3 of your regular rate of pay without using your accruals. **
31. I expect to return to work on:*
    You are eligible to use your accrued paid sick time and any other accrued leave you have available until exhausted. **
33. I would like to use vacation and/or personal leave and then go on an unpaid leave. I am requesting leave until:*
    I will keep the Town updated of any changes.
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35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

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