Public Health Emergency Leave Application Form

Public Health Emergency Leave Application Form

Employee Name*

First Name

Last Name

Employee ID number*

Employee Email Address*

Campus Location*

Anschutz Medical Campus Denver Campus Consolidated Services Administration Academic & Student Affairs

Position Title*

Supervisor Name*

Supervisor Email Address*

School/College/Department*

Department HR Administrator Name*

Department HR Administrator Email Address*

Are you requesting continuous leave or intermittent leave?*

Continous leave Intermittent leave

Leave Start Date*

Estimated return to work date*

What is your work schedule/days and hours you are scheduled to work?*

If requesting intermittent leave, please indicate how many hours per week? *

Can your work be done remotely?*

Yes No

Are you paid on a biweekly or monthly basis?*

Biweekly Monthly

Do you have sick time leave available?*

Yes No

What is your sick leave balance as of 1/1/21?*

Explain the reason you are unable to work *

Check all the Public Health Emergency (PHE) reasons below that apply:*

1. Quarantine / self-isolating because of the communicable illness (COVID-19) in the Public Health Emergency. 2. Seeking a diagnosis, treatment, or care (including preventative care). Includes experiencing side effects after receiving the COVID-19 vaccine. 3. Exposure or symptoms of the communicable illness (COVID-19). 4. Being unable to work due to a health condition that may increase susceptibility to or risk of such illness. This includes a confirmed diagnosis of COVID-19. 5. Caring for a child or other family in category (1)-(3), or whose school or childcare is not available due to Public Health Emergency. 6. Temporary department or workplace closure due to the communicable illness (COVID-19). 7. Respiratory syncytial virus (RSV) - 11/11/2022-1/8/2023 8. Influenza - 11/11/2022-1/8/2023 9. Other respiratory illness - 11/11/2022-1/8/2023