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Coachella Valley Unified School District
SB 114: 2022 COVID-19 Supplemental Paid Sick Leave Form
3/29/2023

SB 114: 2022 COVID-19 Supplemental Paid Sick LeaveJanuary 1, 2022 through December 31, 2022

Last Name: *

First Name: *

Employee #: *

Current Position: *

Site: *

Cell Phone: *

()- Ext.

Home Phone:

()- Ext.

Date(s) Requested: *

A full-time covered employee may take up to 40 hours of leave if the employee is unable to work or telework for any of the following reasons:

REASONS:

Vaccine-Related: The covered employee is attending a vaccine or booster appointment for themselves or a family member or cannot work or telework because they have vaccine-related symptoms or are caring for a family member with vaccine-related symptoms. An employer may limit an employee to 24 hours or 3 days of leave for each vaccination or booster appointment and any consequent side effects, unless a health care provider verifies that more recovery time is needed.

Caring for Yourself: The employee is subject to quarantine or isolation period related to COVID 19 as defined by an order or guidance of the California Department of Public Health, the federal Centers for Disease Control and Prevention, or a local public health officer with jurisdiction over the workplace; has been advised by a healthcare provider to quarantine; or is experiencing COVID-19 symptoms and seeking a medical diagnosis.

Caring for a Family Member: The covered employee is caring for a family member who is subject to a COVID-19 quarantine or isolation period or has been advised by a healthcare provider to quarantine due to COVID-19, or is caring for a child whose school or place of care is closed or unavailable due to COVID-19 on the premises. (A family member includes a child, parent, spouse, registered domestic partner, grandparent, grandchild, or sibling.)

A full-time covered employee may take up to an additional 40 hours of leave if the employee is unable to work or telework for either of the following reasons: (Please note that the positive result(s) will need to be provided in order to receive this allotment of Supplemental Paid Sick Leave.)

REASONS:

The covered employee tests positive for COVID-19

The covered employee is caring for a family member who tested positive for COVID-19. (A family member includes a child, parent, spouse, registered domestic partner, grandparent, grandchild, or sibling.)

Part-Time covered Employees: Part-time covered employees may take as leave up to the amount of hours they work over two weeks, with half of those hours available only when they or a family member test positive for COVID-19.

Retroactive, SB114 is retroactive as of January 1, 2022. If you took time off due to COVID-19 related purpose and seek reimbursement, provide the date(s):

Attach documentation justifying qualifying reason:

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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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