b'FORMS/HANDOUTS REMOTE WORKER RESOURCESFamilies First Coronavirus Response Act uestFamilies FirstoCoronavirus Response Act(FFCRA) to emergency paid sick leavetiand/orfRemote Worker Compliance Essentials KitEmployee Leave ReqEligible f d family may beed entitled under theynathe reas ioquuse re related to COVRAID, -p1le9.a sTeh seu bammiot utnhs oreq leuaevset FFCRA Leave Request Formexpand eemployees and mical leave if th eo re unabolen (ts) fw st alesoavnes under the FFCpoerrm tmito ytedo uar hndu ammaon runets oofu rpcaeys m vaarny abgaer osedr supervisor as soon as you become aware of the need for leave.oro rleka vfoe.rTvoa rreEmployee InformationEmployee ID #_________________________________________A0103Name: ________________________________________________ Job Title: _____________________________________________ A0105Department: ___________________________________________ Supervisor: ___________________________________________ Get everything you need to manage a remote workforce for the first time.// //Todays Date:_____________ Hire Date: ______________Status:Ful-Time Part-Time Temporary Satisfy mandatory DOL and IRS recordkeeping requirements by documenting Reason(s) for Requested Leave owing reasons: Kit includes: Employers Remote Work Quick Guide, Emergency Remote Work Preparation Please check all that apply. You may be asked to provide supporting documentation.I am requesting paid leave because I am unable to work, or telework, for the fol _____________________________ details surrounding employees requesting FFCRA leave. Includes EmployersI am subject to a federal, state or local quarantine or isolation order related to COVID-19Name of governmental entity ordering quarantineI have been advised by a health care provider to self-quarantine due to COVID-19 ___________________________________ Checklist, Supervisors Tips for Managing Remote Workers (pack of 10), Employee Tips for I am experiencing symptoms of COVID-19 and seeking a medical diagnosisb Name of health care profesional advising self-quarantine Tip Sheet covering compliance guidelines and recommended best practices.________________________________________Date of apointment and name of health care profesionalI eaenmcaadrviingsed fo bry a anhienadltivhi dcuaarelwprhoov iids ersu btoje scetl ft-oq ua aferaderntianl,e s rtealtaet oedrltooc CalO qVuaIDra-n1t9ine or isolation related to COVID-19, or who has ______________________________________________________________________________________________________ Working from Home (pack of 25), Telecommuting & Remote Work Policy (pack of 25) and I am o Name and relationship to employe ional advising self-quarantineLEARN MORE ______________________________________________________________________________________________________Name of governmental entity ordering quarantine or health care profesName of Schol/Place of Care that is closed Remote Work Request Form (pack of 25). COV cIDar-i1n9g.fI ocre mrtiyfy c hthiladtbneoc aouthseer h pise/rhseorn s wchiol ble o prr polvaicdei nofgccaarreehfoarscthloes cehdi, lodr d huirsi/nhge rt hche iplderciaordefporro vwihdeicrh i sIuanma vreaiqluaebslet induge p taoid leave. ____________________________________________ _______________________________________________________Name and age of child___________________________________________________________________________________________________If yo Name and age of child Name of Schol/Place of Care that is closed LEARN MORE ____________________________________________ _______________________________________________________Name and age of childName of Schol/Place of Care that is closedve to provide childcraorve dide curaing dre foar tylhige cht hhioldu:rs for a child older than age 14, please describe the specialcircuu amsrte ranecqes tuehstaing lt exeisat requiring you to p ____________________________________________________________________________________________________________________________________________________________________________________________________________Other, including any other substantially similar condition specified by the Secretary of Health and Human Services: _____________________________________________________________________________________Also available as a download: A0105DL _____________________________________________________________________________________Also available as a download: A0103DLEm e Certoifrikcationto Rpletuoyren to WComplete this self-cenrttiafcict watiioth an fon irmn dpirviiodru toal d yoiuagr nreotsued orn tr so whoowrki nifg s yoyum: (p1t)o hms oave hf CadO sVymIDp-t1o9m; os r (of 3C) hOaVvIe beD-1e9n ;( Employee Certification to Return to Work Mandatory Employee Handout Serviced2i) h icial.recatved te ho sad cellfo-isse colaote or quarantine by your healthcare provider or a public health ofUpon completion, return thg de foocrm tumo yentoatuir hon. Fumaialn rure teso pourrcoeps merly canaogmer opletr se aupned srvuisbomr ait ts dhie frecortedm m. Yoay pu mreavy be ent aysoku fed troo pm rretovuirdne sinug tppoo wrtoinrk. A0107 UW12HNDEmployee Information Name: ________________________________________________Employee ID #_________________________________________Document that employees returning to work after illness or exposure are symptom-freeComply with ever-changing federal, state and local employment laws that require Department: ___________________________________________Job Title: _____________________________________________// //Todays Date:______________Hire Date: ______________Supervisor: ___________________________________________Status: Ful-Time Part-Time Temporary and safe to return. Form complies with ADA and includes important reminders foremployers to distribute certain written notifications directly to employees. Service Employee Self-Certification I, ____________________________________________, hereby certify that ALL of the folowing statements are true and accurate:1 I haatev eo hf alads tn foe vferev eroff1o0r0 a.4t leFa osrtthhirgeheer d: a ______________ys (72 hours) without taking fever-reducing medication.employees to self-monitor and report any symptoms. Includes Employers Tip Sheetincludes all of the latest COVID-related notices regarding emergency leave, social D //spiratory symptoms began. 2 At leastv er10adnady/so hr arvees ppiarsasteodr ys isnycme pmtoym fesv bere gaannd: /______________or re //Date fe3 If applicable, my respiratoryp tsoymmsp btoemgasn ( cimoupgrho vainngd: s ______________hort // covering compliance guidelines and recommended best practices.distancing, sick leave, unemployment insurance, separation notices, and more.nes of breath) have improved. D4 Ina tteh ew phaenst1r0es dpairyast,o Ir yh asvyem not been in close contact with anyone exhibiting COVID-19 symptoms or testing positive for the virus.5 I am not subject to a directive to self-isolate or quarantine bpyt oam hse a(el.tgh.c, afervee pr,r coovuidgerh,oorrsah pourtbnliecs sh oefa lbtrhe aotfhfi),c Iia ml. ust folI uuinddeleirnsteasn adn dth iantf oifr Im e xmpaenriaegnecme ae nrte -imemmeerdgeiantceely o. f( PCleOaVseI Dref1e9rstoy mthe CDCs website for a list of COVID-related symptoms and any updatesow isolation t The service updates as requirements change.go this guidance.) // LEARN MOREDate of Requested Return to Work: ______________ Employee Signatureas subject me to discipline up to and including termination. LEARN MOREI certify and atest that the above information is true and accurate to the best of my knowledge. I understand that misrepresentation of any of this information may prevent me from returning to work, as wel//Employee signature: ___________________________________________________________________Date: _________________EMPLOYER: Treat this form as a medical record, keping it separate from employe personnel files and only alowing aces to designated personnel.200120707 DCLo_mDpolywRniglohta, dInc. A Thins iopnros dounc ta nisy d sepsiegcnifeicdftaoc tpsr oorvi sdeer aviccceusr. aTthe ea nindf aorumthagoetrisio tanart iiissvi pen girno ovfuoidrtem odafwtthiioetn hu.Hst I o ho eo wure nivndeaerbr, ilttia tisyndtnioon tug a st esh utahbti sast npityruo ptdee ufrcsootr .nl Ye s i o g orau lenaadrtevit yuicr eign aevdno dtlv ode ocdoe isnn sn ucorltetpaatnrio navgti,tdo per rlnoeedgyau lc ing Also available as a download: A0107DL opicr npdcoiserrtrtnaiinbnutg tn iynoogtue :trh T pihsa ripst riicosud alupacprt rs ioist vuneadott i foloinarbaulnsee d fo bayrnaytnh syeppedcuaimrfcicahaser only. This form may not be shared publicly or with third parties.omquestions or concerns you may have.eRemote Work Request Position:_____________________________________Employee Remote Work Request Form 6-Month Intranet Licensing Service for Remote Worker Employee Information Name: __________________________________________________________I.D.#: _______________________ Department: ________________________Supervisor: __________________________________ A0147 Posting Compliance// //Hire Date: ___________________Date of Request:_____________________Reason(s) for RequestI would like to work remotely as folows: I am requesting to work remotely on the following dates (indicate specific dates and/or date range(s), if applicable): Simplify and standardize the process by which employees can inquire about_______________________________________________________________________________________________________ UW0600NET_______________________________________________________________________________________________________I am requesting to work remotely on an ongoing basis, as folows (indicate number of days per week and other details as applicable): the possibility of working from home to reduce exposure. Includes Employers_______________________________________________________________________________________________________ Provide electronic postings for any employee that does not visit several times _______________________________________________________________________________________________________Please describe how you think your job responsibilities are suited for working remotely:_____________________________________________________________________________________________________________ Tip Sheet covering compliance guidelines and recommended best practices. _____________________________________________________________________________________________________________ a month a location where postings are displayed.Simply place a link on your I have discused working remotely with my supervisor and understand that my request does not guarantee that I wil automaticaly be eligible. I have read the Companys policy on telecommuting and/or remote work, and understand that it is not appropr.iate for every employee or job position. I understand that the ability to work remotely can be terminated at any time by the Company // LEARN MORE company intranet site to provide employees with immediate access to the latest Employees Signature: ________________________________________________________________ Date: __________________Manager/Supervisor ApprovalBy signetc ing beemlopwlo, Iy eaec kisn aonw alepdgpreo pthriaat teIhcaanvedi didascteu sfosred w tohrek inpogs sriebmiliottye loyfbwaosrekdin ognrheims/hoteerl yj owbi rthes tphoen asbiboivlie-ntiesa maneddpeemrfpolromyeaen, caen indthhias/ht Ier bur trhoilse or position. Date: __________________ postings. Includes all of the mandatory federal, state, city and county postings;elireevnSupervisors Signature: _______________________________________________________________ //For Office Use OnlyAPPROVED Provide Details: ________________________________________________________________________________ and updates as posting laws change.________________________________________________________________________________DENIED Reason: Job position and/or specific responsibilities not suitable for remote work at this timeOther: _____________________________________________________________________________Supervisor/HR Managers Name: ___________________________________________________________________________________ LEARN MORE// Supervisor/HR Managers Signature:T or I _____________________________________________________ prso o orin g Date: _________________Also available as a download: A0147DLA20104207 DCoL_mFpillylnRSigahvte, Inc. ophiins iponros dounc ta ins yd sepseigcinfeicdftaoc tpsr oorv isdeer aviccceusr.a The informicaag quest s inn nfvoidred c athoii n. it iysn d tnoion tuuseb ltihcilsyor with third parties.cm te and authoetrisio tnaart iiinisoly. This form may not be shared pa t hsuabt satnpityur otpdee fruoscrotn . lYe ogorau elanardteivt yuic riegn aevndod ltv ode dcooe insn s ncuorltetaaptnrion avgti,tdo perr olneedgyua cl ing o ndpcoiserrttrnaibinnut gtn iyonogtue tr: h Tpisha ripst riicos dualupacprt rs ioistv uneoadt ti flooinarbualsneed fobarynatynh syeppdeaucimrfchaser o ve igotmof twe ehtHhe wu nevdeaerb,rsiltaiatve.oru conrtn susyeo u may hStaying Safe at Work During COVID-19 COVID-19 Prevention and Stress Handout There is currently no vaccine to prevent the new coronavirus disease 2019 (COVID-19).Poster GuardE-Service for Remote WorkersPreventative measures are your first line of defense. The folowing is general workplace health and safety information to help prevent the spread of COVID-19.What is COVID-19? an spread from person to person. The virus that causesN0075C UW1200RDLCOOVVIIDD1199 i ws a ras fiersstp iirdaetnotriy ifieldln deuss trinhga at cn investigation into an outbreak in Wuhan, China. How does COVID-19 spread? Give employees a concise explanation of what COVID-19 is, how it spreadsThe virus is thought the co sopronavirus cread mainloy fugrohm pe, sneersoze on-r tto-apelk. Trsohen. Tse dhe vropirlues sts cparn leadans bd iy dn trhoe mpletos muthas ode rDeliver mandatory federal, state, county and city postingsincluding the w ith tnohseen peos of people wple nearby or be inhaled into their lungs. How do I protect myself from COVID-19 at work? and ways in which they can protect themselves and others. The 8x 11 formKeep Things Clean s. If soapFFCRA poster via email to employees who do not frequent facilities where Wanads hw ayoteurr a hraen ndost o afvtaeinla fboler ,a ut sleea asnt2a0lc osehcool-nbdass.e Tdh hisa wndilshaenlpit izweilrltphraott eccotn ytoaiun sfr aotm le gaesrtm 60% alcohol. You should wash yhe bouar hthraoondms:is printed, front and back, on thick paper stock.After usinug tring and after food preparation physical postings are displayed. Receipt acknowledgments are tracked forBefore, dawtiinng fg yoooudr nose, coughing or sneezing Beftfeor bre elo A LEARN MORE easy verification. Service is ideal for home-based workers and other remoteAfter caring for someor one wther aho ins simaiclk os or tr ahfteeir fr coohad anginnd wg a cashtields diaper Afftteer tr hoauncdhliinng peg garts obage AAvoiAvd Coid clolsoe Cse coonnttacact wt ith people who are sick. If you are sick, keep your distance from others.workers with internet access.CovSenr Ceezoe iugnhs ato yonud Sr elbnoew oezer a ts issue and then throw the tissue away and wash your hands.Avoid Touching Youpr Ereear ed wyehes, nn a peose, or mouth.LEARN MOREG yes, Nose orr Mson touotuhches something that is contaminated with germs and theern tms aource ohes hften sis or hStay Home Wotom e fothreorm ws. S hen Yooru Ak anre Sd avicok id running errands when you are sick to prevent spreading your iltnaey hssClean Your WorkstationCelesakn as, cll foureqnteuretonptly ts, dooouchrked snobus arfancd mes in ticrohwe wave borkputlatocne, ss wucith ah ds kisinefyecbotaanrdtss., remote controls, Also available as a download: N0075DLdSource: Centers for Disease Control and Prevention12 HRDIRECT.COM 800.999.9111 13'