COVID Paid Sick Leave Request

Instructions:

Please refer to the Memo at this link: https://www.tompkinscountyny.gov/files/assets/county/v/1/human-resources/documents/medical-leave/nys-paid-covid-leave-memo-updated-for-1-1-25.pdf
Employee ID*field type single line
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Last 4*field type single line
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Datefield type date
Date will be captured on form submission
Employee Numberfield type single line
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Employee Last Namefield type single line
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Employee First Namefield type single line
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Submitter

Phone Number*field type single line
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Personal Email*field type email
Job Titlefield type single line
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Date Hiredfield type date

I am requesting COVID Paid Sick Leave for the following dates:
Reason for Request*field type checkbox
Reason for Request1. I have tested Positive for COVID-19 and I am subject to a mandatory isolation or quarantine order per NYS Health Commissioner and will upload the two (2) required documents below when prompted.
Start Date of Leavefield type date
End Date of Leavefield type date

Reason for Isolation or Quarantine*field type radio button
Note: Acceptable Positive test document examples: a picture with my name & date of a Positive Home Test or Lab Results with date of Positive Test Result.
Reason for Isolation or QuarantineI have tested positive and have uploaded both required documents (NYS Affirmation Form & Positive Test Result Document) within this form.
Upload Quarantine/Isolation issued by NYS Health Commissioner (NYS Affirmation Form) and Positive Test Result Document.*field type file upload
Drop files here
You have reached the maximum file limit: .
Please provide a statement of inability to work or telework and any “extenuating circumstances” below.

COVID-19 Immunization/Booster

Please note that to claim this time for COVID-19 Immunization/Booster, you MUST receive the immunization/booster during your normal/regularly scheduled work hours.
Date of Immunization/Boosterfield type date
This date may NOT be a future date. Please fill out this form AFTER you receive your immunization/booster.
Total Time Taken Including Travel Timefield type number
Upload Immunization/Booster Card*field type file upload
Upload copy of medical documentation showing RECEIPT of vaccine including date and time (do not use future dated documents).
Drop files here
You have reached the maximum file limit: .
Future dated vaccine appointment is NOT Verification of Vaccination

Please provide a Statement of Inability to Work or Telework and any "Extenuating Circumstances"*field type richtext
Once this form has been reviewed, you will get a confirmation email with directions on how to put this on your timesheet.