2022

To request COVID-19 Supplemental Paid Sick Leave as provided under SB 114. Please complete the following request form.

Refer to the appropriate Supplemental PSL Chart available online according to your position. http://www.vesd.net/departments/personnel_services/covid19leave

First Name:
Last Name
Classification
Position
Department/Location
Supervisor
Requested Leave Start Date: Requested Leave Start Date: / MM / DD YYYY
Estimated End Date: Estimated End Date: / MM / DD YYYY
If your request includes a partial day, indicate the date and number of hours
Reason for Supplemental PSL Request

Refer to the charts available on the VESD website under Personnel, COVID-19 Leave
If the reason for your leave request is related to a COVID-19 Vaccine, please indicate the date below:
Date of COVID-19 Vaccine
Employees may upload their vaccination record online:

https://documents.vesd.net/Forms/covid19vac
If the reason for your leave request is to care for a child whose school or place of care is closed or unavailable due to COVID-19 on the premises, complete the required information below:
Name of Child's School or Place of Care

Supplemental PSL Request Form Eff 2/19/2022

Supplemental PSL Request Form Eff 2/19/2022

If the reason for your leave request is related to a COVID-19 Vaccine, please indicate the date below:

Employees may upload their vaccination record online:

If the reason for your leave request is to care for a child whose school or place of care is closed or unavailable due to COVID-19 on the premises, complete the required information below: