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Requirements and Sample form for Families First Coronavisus Response Act (FFCRA)

09 Apr 2020 10:14 AM | Kate Nolin-Smith


Under DOL regulations, employers may require certain information from employees to verify the need for FFCRA leave. More importantly, under IRS guidance, to take advantage of the payroll tax credits, employers are required to obtain and retain (for four years) certain information. The following enumerates all categories of information discussed by the DOL and IRS.

Initial Information from Employee

Initially, employers should memorialize the following information, which may be provided orally by the employee. If provided orally, according to the DOL/IRS, the employer should document the oral statements.

 Employee’s name

 Dates for which leave is requested

 Qualifying reason for leave

 Statement that the employee is unable to work or telework because of the qualifying reason.

Additional Information from Employee

The regulations further specify forms of additional documentation based on the reason for leave. In each instance, the information may be provided by the employee and does not require any further certification, such as by a health care provider. The nature of the additional information depends on the reason for leave:

For leave requested pursuant to an order to isolate or quarantine -- identify the government entity that issued the order.

For leave based on advice of a health care provider to self-quarantine -- the name of the healthcare provider; and, if the leave is to care for another individual, the identity of and relation of the individual to the employee.

Although not mentioned in the documentation rules, the DOL regulations define an “individual” as someone with whom the employee must have a personal relationship. Examples: an immediate family member, a person who regularly resides in the employee’s home, or a similar person with whom the employee has a relationship that creates an expectation the employee would care for that person if quarantined.

For leave due to a school closure or unavailability of childcare -- (1) the name of the child; (2) the name of the school, place of care or childcare provider that closed or is unavailable due to COVID-19; and (3) a statement that no other suitable person is available to care for the child during the period of requested leave.

In addition, under IRS guidance issued on the same date as the DOL regulations, an employer can require that, if a child is over 14 years and care is during daylight hours, the employee provide a statement of “special circumstances” requiring employee to provide care.

IRS Required Documentation

Additionally, the IRS requires that employers maintain documentation related to the following:

 How the employer determined the amount of EPSL or FMLA-PHE Leave paid to employees, including records of work, telework and leave

 How the employer determined the amount of qualified health care expenses allocated to wages

 Completed Forms 7200 submitted to IRS (Advance of Employer Credits)

 Completed Forms 941 (Employer’s Quarterly Federal Tax Return) submitted to IRS

Track Documentation

Employers should set up a system to gather the information from employees seeking leave. If the employee does not respond or provide all required information, notify the employee of the deficiency and give them a reasonable period (7 calendar days) to cure the issue. If the employee fails to cure the issue, even after being notified, the employer is not required to provide paid leave under the FFCRA.

Sample Form

Leave under the Families First Coronavirus Response act (FFCRA)


To request Emergency Paid Sick Leave (EPSL) or paid FMLA Public Health Emergency Leave as provided under the FFCRA, please complete the following Request and Documentation Form and submit to the Human Resources Department as soon as possible, but not later than five (5) working days after the first workday missed. 

For FMLA Public Health Emergency Leave, only leave required for reason No. 5 below applies, and notice of the request for leave must be provided as soon as the need for leave is foreseeable.

Employee Name (Print):


Manager Name:

Requested Start Date:

Estimated End Date:

The reason for this leave request is (check the appropriate reason below):

 (1) I am subject to a federal, state, or local quarantine or isolation order related to COVID–19.

Name of governmental entity ordering quarantine:  ______________________________________

 (2) I have been advised by a health care provider to self-quarantine due to concerns related to COVID–19.

Identify the health care provider’s name, specialty, and address:  ___________________________________________________________________________________________________________

 (3) I am experiencing symptoms of COVID-19 and seeking a medical diagnosis Identify the health care provider’s name, specialty, and address:  _____________________________________________________________________________________________________________

 (4) I am caring for an individual who is subject to either Reason 1 or 2 above. Identify the name of the individual and relationship to you:  _________________________________________________________________________________________________________________

Does the individual reside in your home?  _______________________________________________

For Reason 1, Name of governmental entity ordering quarantine:  _______________________________________________

For Reason 2, Identify the health care provider’s name, specialty, and address:  _________________________________________________________________________________________________

 (5) I am caring for my son or daughter disabled and needing whose primary or secondary school, or place of care, has been closed, or my childcare provider is unavailable due to COVID-19 precautions.  My son or daughter is under age 18 (or over 18 and incapable of self-care due to a disability. 

Name and ages of all children needing care:  ______________________________________________________________________________________________________________________________

Name of school, place of care, or child care provider that is closed/unavailable due to COVID-19: 


By checking here, I am representing that no other person is available to provide care to the child(ren) listed above during the period for which leave is requested: 

For any child ages 15, 16, or 17 who needs care during daylight hours:  I hereby represent that there are special circumstances requiring me to provide care, as follows:  ___________________________________________________________________________________________________________

 (6)  I am experiencing another substantially similar condition specified by the U.S. Secretary of Health and Human Services.  This condition is:  _________________________________________________________________________________________________________________________________

If you have used EPSL while working for any other employer since April 1, 2020, identify the total number of hours of EPSL you have used:  __________________________________________________________________

Additional Documentation regarding my request is attached.

I hereby certify that I am unable to work or telework due to the qualifying reason identified above.

By signing this form, I certify that the above information is truthful and accurate.  I understand that my employer will rely upon this information in filing for a payroll tax credit with the Internal Revenue Service:

Employee Signature:  ______________________________________         Date:  ________________________

Manager Signature:  _______________________________________        Date:  ________________________

Human Resources Signature:  ________________________________    Date:  ________________________

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