COVID-19 Leave

Your name Your name First Last
Your phone number Your phone number - ### - ### ####
Your district email address:

Confirm email address:
Your position
Start date of COVID-19 leave: Start date of COVID-19 leave: / MM / DD YYYY
End date of COVID-19 leave: End date of COVID-19 leave: / MM / DD YYYY
I affirm that I have emailed the City School District of Albany Health Coordinator to receive my quarantine orders and that this leave request reflects the orders provided to me.

I affirm that I have emailed the City School District of Albany Health Coordinator to receive my quarantine orders and that this leave request reflects the orders provided to me. Check to affirm
I affirm that I am an employee of the City School District of Albany, and that I am hereby unable to work due to COVID-19, as I am subject to a federal, state, or local quarantine or isolation order related to COVID-19 and entitled to 14 calendar days (10 work days) of paid sick leave at regular rate of pay.

I affirm that I am an employee of the City School District of Albany, and that I am hereby unable to work due to COVID-19, as I am subject to a federal, state, or local quarantine or isolation order related to COVID-19 and entitled to 14 calendar days (10 work days) of paid sick leave at regular rate of pay. Check to affirm
Please upload an image or pdf clearly documenting your positive COVID-19 test results:

Attach Files
Please sign below and submit to complete your COVID-19 leave request:

Draw or Type

I understand this field is a legal representation of my signature. Clear

Full Name

I understand this field is a legal representation of my signature.