COVID-19 Leave Request Form

Per the recently passed Families First Coronavirus Response Act (FFCRA), Five Points Healthcare will provide paid sick leave and/or expanded family and medical leave for specific COVID-19 related circumstance where an employee is unable to work (or unable to telework). Prior to completing this form, please contact your supervisor to discuss the availability of telework options.

April 1, 2020 is the earliest possible leave date.
For leave reasons #1 to #3, employees are eligible for two weeks of paid sick leave at their regular rate of pay, up to $511 per day and $5,110 in total. In most jurisdictions, home health and hospice agencies are considered "essential businesses" and exempt from isolation orders.

For leave reason #4 and #6, employees are eligible for up to two weeks of paid sick leave at 2/3 their regular rate, up to $200 per day and $2,000 in total.

For leave reason (5), employees are eligible for two weeks of paid sick leave plus an additional 10 weeks of paid expanded family and medical leave at 2/3 their regular rate, up to $200 per day and $12,000 in total.

Part-time employees will be prorated based on their average hours/units worked.

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