COVID-19 Shared Leave Request Form

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Please use this form to request leave from our COVID-19 Shared Leave Bank. Leave donated through this program is to support university employees who are unable to work due to certain COVID-19-related reasons, who are receiving less than full paid leave, and who have exhausted all of their own personal leave balances.

Employees may request leave from our COVID-19 Shared Leave Bank for absences if the employee cannot report to work onsite or telework because the employee:

must provide child care because a school or child care facility remains closed, or the school has required or has allowed remote learning, due to COVID-19;
must provide elder care because an elder care facility is closed due to COVID-19;
has been in close contact with a COVID-19 positive person in the last 14 days;
received instructions to isolate or quarantine by a public health official or health care provider;
has COVID-19 symptoms and seeking medical diagnosis or has been diagnosed with COVID-19; or
is not expected to report to a University worksite but cannot telework because their position and duties cannot be performed remotely and because reasonable alternate remote work is not feasible or productive.

To be eligible, employees must exhaust all forms of their own personal leave and any newly accrued leave must be applied before additional shared leave can be awarded.

Requests for leave from the shared leave bank must be made by the 15th of each month, to allow time to process in advance of each monthly payroll.

Leave from the shared leave bank will be distributed equitably and our ability to provide requested leave is dependent upon availability.

If you are provided with donated leave, you will be provided instructions for how to complete your timesheet or leave report.

Personal Information

First Name *

Last Name *

Banner ID *

Best phone number to reach you (Cell or Home): *

Email *

Request Form

Leave balances may be checked online through Employee Self-Service

I meet the above criteria and have already exhausted my personal leave and will not have enough leave to cover this pay period. *

Yes

This criteria applies to me: *

I am not required to work on campus and cannot telework because of the nature of my position.

I am unable to work due to child care needs caused by a COVID-19 school or child care closing.

I am unable to work due to elder care needs caused by a COVID-19 facility closure.

How many hours of donated leave do you need to request for this payroll period? *

hours

STOP - you may not be eligible for donated leave. To be eligible to request shared leave, you must meet the above criteria and have already exhausted your personal leave and will not have enough leave to cover this pay period. If you have questions about this policy, please contact the Office of Human Resources.

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