COVID-19 Resources

Requesting Sick Leave for Medically Advised Self-Quarantine or Stay-at-Home

The Families First Coronavirus Response Act provides 2 weeks of paid leave to eligible employees who need leave because they have been advised by a health care provider to stay home or self-quarantine due to concerns related to coronavirus. This fillable form helps employees who want to request leave and their employers by asking for the information required by law to grant leave requests. It is not legal or tax advice. Employees who want to request leave should complete the sections that apply to them and give the completed form to their employer.

What's the law?

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Overview of Legal Rights for Sick Leave

  • The Families First Coronavirus Response Act applies only to private businesses that have fewer than 500 employees and to government agencies of all sizes.
  • An employee is eligible for 2 weeks of emergency paid sick time when they need leave because they have been advised by a health care provider to stay home or self-quarantine because they may have COVID-19 or are particularly vulnerable to COVID-19.
  • During the time off, employers must pay the employee their regular rate of pay or the minimum wage that applies where they work, whichever is more. Employers are not required to pay more than $511 per day or $5,110 total. Employers may not require an employee to use sick days, vacation time, or other paid time off before taking two weeks of emergency paid sick time, or while taking the emergency paid sick time.
  • If an employer and employee agree, the employee may take part-time (“intermittent”) leave, so long as they are teleworking.
  • Employers receive tax credits to cover costs associated with providing paid leave. See the Internal Revenue Service for details.
  • For more information, view frequently asked questions and answers from the Department of Labor.

Who is left out of the Families First Coronavirus Response Act?

  • Emergency employer-paid leave and sick time is not available to all employees:
    • Employers may provide paid leave to healthcare providers and emergency responders, but they are not required to do so.
    • An employee is not eligible for paid leave if their employer does not have work for them to do during the time they need the leave (e.g., if their worksite is closed or they are furloughed).
  • Employees who are not eligible or use up their paid leave under the Families First Coronavirus Response Act may be eligible for job-protected leave under the Family and Medical Leave Act, the Americans with Disabilities Act, and/or other federal, state and local laws. They may also be eligible to collect unemployment insurance, pandemic unemployment assistance, paid family leave, or other benefits from the state where they work.

Are you already off work without pay?

You may be eligible for state benefits like Unemployment Insurance or Pandemic Unemployment Assistance. You can find out more by contacting your state’s unemployment office or going to its website.

Requesting Paid Time Off

Click the button below to complete a form that includes the key information you are required to provide your employer to receive paid sick leave because you’ve been medically-advised to stay home or self-quarantine.

Form to Request COVID-19 Sick Leave Because of Medically-Advised Self-Quarantine

Still have questions?

Call the Center for WorkLife Law’s free COVID-19 Legal Helpline for more information: 415-851-3308 or

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Learn about WorkLife Law’s COVID-19 Resources and Helpline