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Coachella Valley Unified School District
Senate Bill 95 Form
10/16/2021

SENATE BILL 95

 


Last Name: *
First Name: *
Employee #: *
Current Position: *
Site: *
Cell Phone: ()- Ext.
Home Phone: ()- Ext.
Date(s) Requested: *

Qualifying Reasons for COVID-19 Supplemental Paid Sick Leave. An employer must provide COVID-19 supplemental paid sick leave to each covered employee if that covered employee is unable to work or telework due to any of the following reasons: 

 

 

REASONS: *
The covered employee is subject to a quarantine or isolation period related to COVID-19 as defined by an order or guidelines of the State Department of Public Health, the CDC, or local health officer. If the covered employee is subject to more than one of the foregoing, the covered employee must be permitted to use COVID-19 supplemental paid sick leave for the minimum quarantine or isolation period under the order or guidelines that provides for the longest such minimum period.(This does not include a general stay-at-home order.)  
The covered employee has been advised by a health care provider to self-quarantine due to concerns related to COVID-19.  
The covered employee is attending an appointment to receive a COVID-19 vaccine for protection against contracting COVID-19.  
The covered employee is experiencing symptoms related to a COVID-19 vaccine that prevent the employee from being able to work or telework  
The covered employee is experiencing symptoms of COVID-19 and seeking medical diagnosis.  
The covered employee is caring for a family member who is subject to a quarantine or isolation period related to COVID-19 or who has been advised to self-quarantine due to COVID-19.  
The covered employee is caring for a child whose school or place of care is closed or otherwise unavailable for reasons related to COVID-19 on the premises.  
Retroactive, SB95 is retroactive as of January 1, 2021. If you took time off due to COVID-19 related purpose and seek reimbursement, provide the date(s):  

If requesting retroactive reimbursement, you will need to submit a revised timesheet to payroll.

Please check qualifying box above. Attach documentation justifying qualifying reason (i.e., immunization record, doctor letter or school schedule). 

Attach documentation justifying qualifying reason: Click to Upload Files
FOR CHILD CARE (PROVIDE)
Name of Child:
School/Childcare:
School/Child Care Provider Telephone #: ()- Ext.

BY SUBMITTING FORM, I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I FURTHER UNDERSTAND THAT ANY FALSE STATEMENT MAY RESULT IN DISCIPLINARY ACTION, INCLUDING TERMINATION OF EMPLOYMENT.

 

Employee Electronic Signature: *
Date:
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