Request for COVID-19-related Paid Sick Leave

Dear [employer]_______________________,

I am requesting leave from [date]_______________ to [date]___________________.

I need leave because (circle one):

  • I am subject to a quarantine or isolation period or was exposed and am following the guidance of California Department of Public Health, the federal Centers for Disease Control and Prevention, or a local health officer
  • I have COVID-19 symptoms and am seeking a diagnosis
  • I am receiving a COVID-19 vaccine
  • I am recovering from a COVID-19 vaccine
  • I need to care for a family member who is ill with or exposed to COVID-19
  • (if your employer has 26 or more employees) I need to care for my child because their normal care is unavailable because of COVID-19 on site.

(also circle one of the below for leaves beyond your available paid sick leave)

  • I am temporarily disabled from working by a serious health condition or disability.
  • I need to care for my seriously ill family member.

I request my COVID-19 Supplemental Paid Sick Leave pay and/or my CA Paid Sick Days pay.

Please let me know if you have questions.

I can be reached at [phone number or email] ________________________________ .

Thank you,

[name] ______________________________