"Covid-19 Leave Request Form" - City and County of San Francisco, California

Covid-19 Leave Request Form is a legal document that was released by the Department of Human Resources - City and County of San Francisco, California - a government authority operating within California. The form may be used strictly within City and County of San Francisco.

Form Details:

  • Released on January 24, 2022;
  • The latest edition currently provided by the Department of Human Resources - City and County of San Francisco, California;
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City and County of San Francisco
Department of Human Resources
Carol Isen
Connecting People with Purpose
Human Resources Director
www.sfdhr.org
COVID-19 LEAVE REQUEST FORM
Name: ______________________________________
___________________
___________________
REASON FOR THE LEAVE REQUEST
(Please print)
(DSW ID Number)
(Contact Phone)
Address: _____________________________________
_____________________________________________
(Street)
(City, State, ZIP)
Department: _________________________________
_____________________________________________
(Division/Section/Supervisor)
(Department Name)
REASON FOR LEAVE REQUEST and ABSENCE DATES
Public Health or CDC Required Quarantine or Isolation
Health Care Provider Advised Quarantine or Isolation
COVID-19 Symptoms and Seeking Diagnosis – Employee
Care for a Family Member Quarantining or Isolating Per Above
Child(ren)’s School/Childcare Closure/Unavailability
COVID-19 Vaccination Appointment OR Vaccine Side Effects
I Elect to Supplement ESF with Sick Leave, before required leaves.
------
Due to COVID-19
⃝ Employee
⃝ Family Member
Self-Isolation Due to Vulnerable Medical Condition
Absence Dates: From: ____________________________ To: ____________________________ TOTAL HOURS: ________
No intermittent leave for quarantine/isolation or symptoms unless teleworking. Attach schedule for allowed intermittent leaves.
TYPE OF PAY REQUESTED DURING LEAVE
COV Sick Leave
Sick Leave
Vacation
Floating Holiday
Compensatory Time
ONSITE WORK REQUIRED
I cannot work or telework due to a COVID-19 exposure in the workplace or a COVID-19 diagnosis or symptom occurring
within 7 days of being required to work onsite or in the field.
If eligible, you may receive Paid Administrative Leave during any required quarantine period
Employee Signature:
Date:
Supervisor/Manager
Approve
Deny
Signature
(Appointing Officer)
Signature
Eligible
Paid Administrative Leave
Personnel Officer
cc: Official Employee Personnel Folder
th
One South Van Ness Avenue, 4
Floor ● San Francisco, CA 94103-5413 ● (415) 557-4800
(Rev. 1/24/2022)
City and County of San Francisco
Department of Human Resources
Carol Isen
Connecting People with Purpose
Human Resources Director
www.sfdhr.org
COVID-19 LEAVE REQUEST FORM
Name: ______________________________________
___________________
___________________
REASON FOR THE LEAVE REQUEST
(Please print)
(DSW ID Number)
(Contact Phone)
Address: _____________________________________
_____________________________________________
(Street)
(City, State, ZIP)
Department: _________________________________
_____________________________________________
(Division/Section/Supervisor)
(Department Name)
REASON FOR LEAVE REQUEST and ABSENCE DATES
Public Health or CDC Required Quarantine or Isolation
Health Care Provider Advised Quarantine or Isolation
COVID-19 Symptoms and Seeking Diagnosis – Employee
Care for a Family Member Quarantining or Isolating Per Above
Child(ren)’s School/Childcare Closure/Unavailability
COVID-19 Vaccination Appointment OR Vaccine Side Effects
I Elect to Supplement ESF with Sick Leave, before required leaves.
------
Due to COVID-19
⃝ Employee
⃝ Family Member
Self-Isolation Due to Vulnerable Medical Condition
Absence Dates: From: ____________________________ To: ____________________________ TOTAL HOURS: ________
No intermittent leave for quarantine/isolation or symptoms unless teleworking. Attach schedule for allowed intermittent leaves.
TYPE OF PAY REQUESTED DURING LEAVE
COV Sick Leave
Sick Leave
Vacation
Floating Holiday
Compensatory Time
ONSITE WORK REQUIRED
I cannot work or telework due to a COVID-19 exposure in the workplace or a COVID-19 diagnosis or symptom occurring
within 7 days of being required to work onsite or in the field.
If eligible, you may receive Paid Administrative Leave during any required quarantine period
Employee Signature:
Date:
Supervisor/Manager
Approve
Deny
Signature
(Appointing Officer)
Signature
Eligible
Paid Administrative Leave
Personnel Officer
cc: Official Employee Personnel Folder
th
One South Van Ness Avenue, 4
Floor ● San Francisco, CA 94103-5413 ● (415) 557-4800
(Rev. 1/24/2022)
COVID-19 LEAVE REQUEST FORM
Page 2 of 2
REQUIRED INFORMATION (Complete Only Sections That Apply to Your Leave and Sign Acknowledgement)
Public Health or CDC Required Quarantine or Isolation: I am subject to a COVID-19 related public health order or guideline that
prevents me from going to work or teleworking.
Name of public health entity issuing order or guideline: _______________________________________________________________
Order Date: ___________________________ (Employees may be required to provide a copy of the quarantine order.)
It’s not me, instead I’m taking care of a family member subject to such an order or guideline, and I cannot work or telework.
Health Care Provider Advised Quarantine/Isolation: My health care provider has advised me to quarantine or isolate, and I cannot
go to work or telework.
Health Care Provider’s Name: __________________________________________________________________________________
Provider’s Address: ___________________________________________________ City: ________________________ State: _____
Order/Advice Date: ___________________________ (Employees may be required to provide a copy of the medical certification.)
It’s not me, instead I’m taking care of a family member who received this advice, and I cannot work or telework.
Due To COVID-19 Symptoms and Seeking Diagnosis: I am experiencing COVID-19 symptoms and will receive testing or other
diagnostic services.
Provider/Clinic/Test Site Name: _________________________________________________________________________________
Address: __________________________________________________________ City: _________________________ State: ______
Test/Exam Date: ______________________________
School or Childcare Provider Closure/Unavailability Due to COVID-19: I need to care for my child(ren), and I cannot work or
telework because my child(ren)’s school has closed, childcare place has closed or childcare provider is unavailable due to a COVID-19,
and no other suitable person is available to care for my child(ren) during the time I need to take leave. Name(s) and age(s) of
child(ren) I need to care for:
1. ____________________________________ Age: _____
2. ____________________________________ Age: ______
3. ____________________________________ Age: _____
4. ____________________________________ Age: ______
Name(s) of school/childcare place/provider: _______________________________________________________________________
____________________________________________________________________________________________________________
There are special circumstances requiring my leave to care for my child(ren) age(s) 15-17, or adult child age 18, or older.
LEAVE TO SELF-QUARANTINE DUE TO A COVID-19 CLOSE CONTACT OR ILLNESS FROM VACCINE SIDE EFFECTS: I cannot work or
telecommute for one of these reasons.
MY HEALTH CARE PROVIDER RECOMMENDED OR ADVISED ME TO ISOLATE, or told someone in my household that I should
isolate for their safety, because of vulnerability, but I can telecommute or may be able to return to work with accommodations.
Health Care Provider’s Name: __________________________________________________________________________________
Address: _______________________________________________________ City: ___________________________ State: ______
Advice Date: ____________________________
ACKNOWLEDGEMENT
I CERTIFY THAT MY ABSENCE REQUEST IS FOR THE COVID-19 RELATED REASON STATED ON THIS COVID-19 LEAVE REQUEST FORM.
I UNDERSTAND THAT LEAVE AND PAY APPROVED BECAUSE OF THE COVID-19 PUBLIC HEALTH CRISIS IS SUBJECT TO PROVISIONS IN
CIVIL SERVICE RULES, THE MAYOR’S PROCLAMATIONS, AND RELATED RULES PROVIDING LEAVE BENEFITS. I ALSO UNDERSTAND
THAT PROVIDING FALSE OR MISLEADING INFORMATION ABOUT MY ABSENCE MAY RESULT IN DISCIPLINARY ACTION.
Signature: ________________________________________________________
Date: ____________________________
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