GCBDAA/GDBDAA-AR(2) – COVID-19 Related Leave

Employee’s Name: Date:

Dates for which the leave is requested:

Qualifying reason for leave:

• ☐ Is subject to governmental-quarantined or isolation order.
• ☐ Has been advised by health-care provider to self-quarantine.
• ☐ Is experiencing symptoms of COVID-19 and seeking a medical diagnosis.
• ☐ Is caring for an individual who is subject to a quarantine or isolation by governmental order or health care provider advisement.
• ☐ Is caring for their son or daughter whose school or child-care provider is closed.
• ☐ Is experiencing a substantially similar condition related to COVID-19 as specified by the Secretary of Health and Human Services, in consultation with the Secretary of the Treasury and the Secretary of Labor.

The employee is unable to work, including telework due to:

Documentation supporting the qualifying reason for requesting leave:

For quarantine or isolation orders, provide the name of the health care provider who advised the self-quarantine:

Name of health care provider Contact information

For emergency Family Medical Leave Act (FMLA) leave and paid sick leave taken for COVID-19 related school or child care closings, provide documentation to support the need for leave, i.e., notice posted on government, school or day care website, published in a newspaper, or an email from an official of the school, place of care, or child care provider.