What information do I need to collect from an employee who has taken FFCRA leave?

Under the Families First Coronavirus Relief Act, employers must collect a written certification from employees who have taken federally funded leave. An example of suggested content is below.

[EMPLOYEE NAME]

[EMPLOYEE ADDRESS]

[EMPLOYEE PHONE NUMBER]

[EMPLOYEE EMAIL ADDRESS]

Dear [COMPANY NAME],

I was will/be unable to work, including telework, between [DATE] and [DATE] because:

__ I have been advised by a health care provider to self-quarantine.

Name of the heath care provider advising to self-quarantine: _________________

__ I am subject to a Federal, State, or local quarantine or isolation order. 

Name of the governmental entity ordering quarantine or isolation: _____________

__ I am caring for an individual who is subject to an order described above.

Specify the individual, relation to you, and their address: ___________________

Name of the governmental entity ordering quarantine or isolation: _____________

Name of the heath care provider advising to self-quarantine: _________________

__ I am experiencing symptoms of COVID-19 and was seeking a medical diagnosis.

By making this selection, I am confirming that I understand that the symptoms are shortness of breath, fever, dry cough, and other symptoms identified by the CDC. (https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html) 

I understand that leave is provided only for my affirmative steps to obtain a medical diagnosis, such as making, waiting for, or attending an appointment for a test for COVID-19. I also understand that before returning to work, I will need to provide a physician’s note or I will provide an attestation that I have met CDC return-to-work requirements.

__ I am caring for my child under 18 years of age whose school or place of care is closed, or

whose child care provider is unavailable.

Name of child:_____________     Age: ______   

Name of School or Child Care Facility/Provider:

__ I am experiencing any other substantially-similar condition specified by the U.S.

Department of Health and Human Services. 

__________________________

[EMPLOYEE SIGNATURE]