Employee Statement for Emergency Paid Sick Leave (EPSL) Request

Form/Letter
HR Compliance
Paid Sick Leave

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This sample form can be used to document information needed from an employee requesting emergency paid sick leave under FFCRA to substantiate eligibility for tax credits, per the IRS.

The first page of this sample form is applicable for qualifying reasons related to quarantine orders, or advice to self-quarantine from a health care provider. The second page of this sample form is applicable for qualifying reasons related to the employee caring for a child whose school or childcare provider is closed or unavailable due to a public health emergency. Retain this documentation for four years from the date of the request.

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