COVID-19 Leave Request Form

Per the 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). For additional details, please review the Department of Labor FFCRA Notice. Before submitting a leave request, please contact your supervisor to discuss the availability of telework options. Thank you.

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.

Copyright © 2020 Five Points Healthcare, LLC. All rights reserved.