FFCRA Form

FFCRA Form


FFCRA

Employee Data


Section B - Type of Leave Requested

Type of Leave Requested
Select the reason(s) for the leave request

Section C1 - Documentation Quarantine Orders

Health Provider Address
Health Provider Address
City
State
Zip/Postal

Section C2 - Documentation Seeking Treatment

Health Provider Address
Health Provider Address
City
State
Zip/Postal

Section C3 - Documentation Child Care

1. School/Provider Address *
1. School/Provider Address
City
State/Province
Zip/Postal

 


 

2. School/Provider Address *
2. School/Provider Address
City
State/Province
Zip/Postal

 


 

3. School/Provider Address *
3. School/Provider Address
City
State/Province
Zip/Postal

 


 


Section C4 - Documentation Caring for an Individual

Health Care Provider Address
Health Care Provider Address
City
State
Zip/Postal

   


Section D - Compensation under the Families First Coronavirus Response Act

Mandate: 100% Current Compensation for a maximum of 80 hours or the average hours an employee works within a two-week period. Capped at $511 per day.

Mandate: 100% Current Compensation for a maximum of 80 hours or the average hours an employee works within a two-week period. Capped at $511 per day.

Mandate: 100% Current Compensation for a maximum of 80 hours or the average hours an employee works within a two-week period. Capped at $511 per day.

Mandate: 2/3 of Current Compensation for a maximum of 80 hours or the average hours an employee works within a two-week period. Capped at $200 per day. First Responders Excluded.
Use sick or annual leave to supplement compensation? *

Mandate: Initial two-week period unpaid; however, Emergency Paid Sick Leave (FFCRA) at 2/3 Current Compensation. Ten weeks at 2/3 salary. Note: Duration of the leave depends upon FMLA taken within the current FMLA period. First Responders Excluded.
Use sick or annual leave to supplement compensation? *

Mandate: 2/3 of Current Compensation for a maximum of 80 hours or the average hours an employee works within a two-week period. Capped at $200 per day.
Use sick or annual leave to supplement compensation? *

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File Upload
Maximum upload size: 67.11MB
File Upload
Maximum upload size: 67.11MB
File Upload
Maximum upload size: 67.11MB
File Upload
Maximum upload size: 67.11MB
File Upload
Maximum upload size: 67.11MB

Employee Statement of Validation

I have applied for benefits under the Families First Coronavirus Response Act. The information I provided was used by Human Resources to establish eligibility.

I certify that the information I provided is true and accurate. I understand that an audit of the information can be performed at any time by the Human Resources Department.

I understand that this document is an official document of the Clayton County Board of Commissioners, and the information used to establish eligibility will result in budgetary and operational impacts for the County.

I understand that providing false information on this official document can result in disciplinary action up to and including termination, as well as possible repayment of any and all resources received as a result of providing false information.

My signature below attest to my understanding of this document and truthfulness of the information provided herein.