COVID-19 Leave Bank Attestation

Name Name First Last
Employee ID Number
Please indicate below your reason for leave and your use of your COVID-19 leave bank *

Please indicate below your reason for leave and your use of your COVID-19 leave bank Diagnosis with the COVID-19 virus and unable to work remotely Experiencing symptoms of COVID-19 as defined by the Centers for Disease Control, have been tested and awaiting test results in self-isolation Been advised by Occupational Health, the University PHCCC, a local health authority or my medical provider to quarantine due to concerns related to possible COVID-19 exposure and unable to work remotely Subject to a federal, state, or local quarantine or isolation order related to COVID-19 and unable to work remotely Advised by a household member’s medical provider to self-quarantine due to concerns related to COVID-19 and unable to work remotely
Please provide documentation for the reason you are requesting COVID-19 sick leave. (Doctor’s note, other similar medical documentation, Occupational Health or PHCCC notification)
Documentation

Attach Files
By signing below, I attest that the above statements are accurate to the best of my knowledge. I understand that providing false information may result in disqualification of COVID-19 Leave Bank pay and/or disciplinary action up to and including termination of employment.
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
If the employee is unable to complete this form or provide a signature please indicate the name of the person completing the form below.
Name of person completing the form Name of person completing the form First Last