Employee Information - McGill Restoration

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Employee Information

COVID-19 POLICY & INFORMATION

McGill Restoration is prepared to comply fully with the Families First Coronavirus Response Act (FFCRA), signed into law on March 18, 2020 and going into effect on April 2, 2020.

FFCRA provides two benefits to employee in an effort to support families during this unprecedented time. One, Emergency FMLA (also called E-FMLA) and two, Paid Sick Leave.

If you think you qualify for either plan, please complete the form below. Once submitted, Human Resources will review your request and provide further information.

Contact Information:

Human Resources – (402) 558-7989

EMERGENCY FMLA & EMERGENCY PAID SICK LEAVE REQUEST FORM

Employee Name *

Email *

Best Phone Number to reach me at: *

Requested Leave Start Date: *

Estimated Return to Work Date: *

The reason for this sick leave request is (select the most appropriate box):

1. I am subject to a federal, state or local quarantine or isolation order related to COVID-19;

2. I was advised by a healthcare provider to self-quarantine due to COVID-19 concerns;

3. I am experiencing COVID-19 symptoms and seeking medical diagnosis;

4. I am caring for an individual subject to a federal, state or local quarantine or isolation order or advised by a healthcare provider to self-quarantine due to COVID-19 concerns;

5. I am caring for my child if the child's school or place of care is closed or the child's care provider is unavailable due to public health emergency (provide further information below); or

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

If you have selected Option 5 from above, please list the name(s) and age(s) of child(ren):

Supporting Documents

Please provide any supporting documents if applicable.

Acknowledgement *

I certify that the above information is accurate and complete.

I understand that if I fail to report to work on or before the scheduled return date indicated above or fail to contact Human Resources regarding my absence from work beyond such scheduled date of return, McGill Restoration may take corrective action.

Signature (Type Full Name) *

By typing full name in the box below, you are acknowledging above statements to be accurate.