HFWA COVID-19 Supplemental Leave Request

Employees requesting COVID-19 Supplemental Sick Leave pursuant to the HFWA (Healthy Families & Workplace Act during Public Health Emergencies) shall complete this form, in as much advance notice as reasonably practical. Effective 1/1/2021, the HFWA COVID-19 Supplemental Leave is available immediately up to 80 hours (for full-time and 3/4 time employees(. For part-time, seasonal, and temporary employees, Supplemental leave is the amount of time an employee works on average in a 14 day period. Supplemental Leave will not be allocated to an employee's accrued Paid Time Off (PTO), Vacation, Sick Leave, or HFWA Leave.

Days out due to COVID-19
Reason for Leave (Check all that apply) "I am unable to return to work (or telework) for the following reasons:

Substitution of Paid Leave:

Substitution of Paid LEave: COVID-19 Supplemental Leave is up to a maximum of 80 hours for full time and 3/4 time employees, available during the entirety of a declared Public Health Emergency.

HFWA COVID-19 Supplemental Leave for other employees (e.g. Part-Time, Seasonal, or Temporary) who normally work fewer than 40 hours in a week, will receive either the amount of time an employee is scheduled to work in a 14 day period or the amount of time the employee actually works on average in a 14 day period, whichever is greater.

*HFWA Leave is sick leave that employers are required to provide all other employees who have not previously been eligible to accrue PTO. This HFWA Leave is accrued at a rate of 1 hour per 30 hours worked, up to 48 hours.


By signing below, I certify the above information is accurate and complete. I understand that if I fail to report for work on or before the scheduled return date, indicated above, or fail to contact Human Resources regarding my absence from work beyond such scheduled date of return, my employer may take corrective action up to and including termination.