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Colorado Public Health Emergency Leave Request Form

Thank you for completing this leave request form. Be as detailed as possible. If you do not provide sufficient explanation or documentation, your paid leave may be delayed until you have provided the required information

Need to self-isolate or care for family member that needs to self-isolate due to positive diagnosis.
Need to seek (or care for a family member who needs) medical care due to symptoms.
Need to seek preventative care concerning a communicable disease.
Ordered to quarantine by a local, state, or federal public official or health authority
Prohibited from working by the client where I am assigned due to health concerns related to potential transmission
Need to care for a child or other family member when the childcare provider is unavailable due to a public health emergency.

Thanks for submitting!

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