COVID-19 RELATED FAMILY MEDICAL LEAVE​

This page is to be used solely for those employees requesting time off per the Family First Coronavirus Response Act (FFCRA). Complete all sections of the request form below, and include corresponding documentation before submitting. You will receive packet and instructions via email within 24 hours, given all verified documentation has been included with your submitted request.

    EXPANDED FAMILY MEDICAL LEAVE ACT (revised)
    FFCRA REQUEST FORM - CORONAVIRUS RELATED ONLY
    Complete all fields below and click SUBMIT
    Additional information about employee rights and responsibilities under the Families First Coronavirus Response Act (FFCRA) is provided HERE. 

    Determination of eligibility for leave, and/or additional documentation or clarification of documentation, may be required prior to making a final determination to approve or deny an eligible expanded family medical leave request under the FFCRA.
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    Please contact Human Resources directly at HRHelpDesk@southernmedical.com with any questions you may have before submitting your request.
    Max file size: 20MB
    Max file size: 20MB
    Note: Incomplete information or lack of documentation may cause delay or denial of the benefits provided by this request after submittal.
    By submitting this form, you are stating that all information above is correct and true, and that you have read and understand the "Rights and Responsibilites under the Families First Cronavirus Act".