COVID-19 Paid Administrative Leave Application

PLEASE NOTE: COVID-19 Paid Administrative Leave is only available for employees who meet the detailed requirements and were on leave before July 27, 2022.

In order to be eligible for this paid administrative leave, employees must complete this application.

Suitable documentation must be provided to support the need for COVID-19 Paid Administrative Leave usage. If an employee is found to have falsified the need for leave, the employee may be denied the leave and/or may be subject to disciplinary action up to and including termination.

COVID-19 Paid Administrative Leave will not be granted without proof of vaccination status or evidence of a granted accommodation and full compliance.

Name Name * First Last
E-Number *
EIU Email *
Contact Phone Contact Phone * - ### - ### ####
Work Phone Work Phone * - ### - ### ####
Department *
Supervisor Name Supervisor Name * First Last
Beginning Date for Leave Beginning Date for Leave * / MM / DD YYYY
Estimated Date of Return Estimated Date of Return * / MM / DD YYYY
Normal Work Schedule (Days & Times) *
Type of Leave *
Please select the covered reason that applies for your request for leave *

Please select the covered reason that applies for your request for leave (1) The employee has a confirmed positive test for COVID-19 via a PCR test or a probable positive test for COVID-19 via an antigen diagnostic test and is required to isolate. (Please note: home tests will not be accepted.) (2) The employee has been in close contact with a person who had a confirmed case of COVID-19 and is required to quarantine. (3) The employee is required by University policy to be excluded from University property due to COVID-19 symptoms. (4) The employee must care for a child
(4) The employee must care for a child who

(4) The employee must care for a child who has a confirmed positive test for COVID-19 via a PCR test or a probable positive test for COVID-19 via an antigen diagnostic test and is required to isolate. has been in close contact with a person who had a confirmed case of COVID-19 and is required to quarantine. has been required by the school or school district policy to be excluded from school district property due to COVID-19 symptoms.
Proof of Vaccination Status *

Proof of Vaccination Status I am or will be fully vaccinated with a COVID-19 vaccine approved by the Food and Drug Administration per EIU COVID-19 Paid Administrative Leave policy. I will provide proof of vaccination against COVID-19. I have been granted an accommodation and am in full compliance.
Please submit a photo of your COVID-19 vaccination card

Attach Files
Medical or Religious Vaccination Exemption *

Medical or Religious Vaccination Exemption I understand that I may qualify for this leave without being considered fully vaccinated against COVID-19 if I have a medical or religious accommodation from the vaccine on file with the University and I am following all the requirements of the accommodation.
Medical Accommodation

Medical Accommodation By checking this statement, I certify that I have an accommodation on file with Human Resources at the time of my leave, and I am following all the requirements of the accommodation.
Religious Accommodation

Religious Accommodation I understand that I must provide Human Resources with a request and receive approval for religious accommodation under this policy. This form must be completed and submitted to Human Resources.
Religious Accommodation As Inability To Be Vaccinated Against Covid-19 Request Form
Please check and make any requested elections on the statements below: *
Please check and make any requested elections on the statements below:
I understand that I need to provide documentation to substantiate my need for leave. If it is found that I have falsified my need for leave, my leave may be denied and/or I may be subject to disciplinary action up to and including termination.
Documentation requirements include:

Reason 1: proof of a positive PCR test result or a probable positive from an antigen diagnostic test OR notice from a local health department of the need to isolate.

Reason 2: notice from a local health department indicating the employee has been identified as a close contact and is required to quarantine.

Reason 3: proof of a positive PCR test result or a probable positive from an antigen diagnostic test or notice from a local health department of the need to isolate; OR notice from a local health department or the student’s school that the child has been identified as a close contact and is required to quarantine; OR notice from the student’s school that the child has been excluded from school district property due to COVID-19 symptoms
I understand that if I intend to use COVID-19 Paid Administrative Leave on a reduced schedule basis, my reduced schedule must first be approved by my department. Should my request be denied, my leave will be processed as a continuous leave of absence. I understand that while on leave I will be required to furnish Human Resources with periodic reports of my status and intent to return to work when requested. I understand that when applying for a Paid COVID-19 Administrative Leave, I am responsible for following my normal departmental call-in procedural requirements until notification of approval has been received. When an employee does not comply with the departmental call-in procedural requirements, Paid COVID-19 Administrative Leave may be delayed or denied. Information and updates regarding my leave will be provided through your Eastern Illinois University email account (xxxxxx@eiu.edu). It is your responsibility to ensure that your email is active and remains active while on leave. If you require any assistance with your email notifications, please contact the Technology Support at 217-581-HELP (4357).
Please submit the following documentation:
- Proof of a positive PCR test result or a probable positive from an antigen diagnostic test OR notice from a local health department of the need to isolate
  OR
- Notice from a local health department indicating the employee has been identified as a close contact and is required to quarantine
  OR
- If you are caring for a child: Proof of a positive PCR test result or a probable positive from an antigen diagnostic test or notice from a local health department of the need to isolate; OR notice from a local health department or the student’s school that the child has been identified as a close contact and is required to quarantine; OR notice from the student’s school that the child has been excluded from school district property due to COVID-19 symptoms.
*
Attach Files
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COVID-19 Paid Administrative Leave Application

COVID-19 Paid Administrative Leave Application

Religious Accommodation As Inability To Be Vaccinated Against Covid-19 Request Form