For District Use Only Clause Samples

For District Use Only. Deposit/Transfer Fee Check #: Paid by Cash: Y / N Identification Type: _ _ Copied for File: Y / N Warranty Deed / Deed of Trust: Y / N Lease/Rental Agreement: Y / N Co-Applicant Signature Date

For District Use Only. Charger provided

For District Use Only. Contract may cover up to one fiscal year of activity. Contracts must be signed by building Principal or Director, and the

For District Use Only. Laptop/iPad/tablet Brand and Model: _ Barcode Number:

For District Use Only. ❑ Request denied by Date School District ❑ Request granted by the governing boards of the school districts above named for the school year 20 -20 , subject to the following terms:

For District Use Only. Staff to complete Routing Initials AND Received Date in this particular sequence:

For District Use Only. Request Received By: Date: Leave Approved By: Date: Period of Leave: Employees may be entitled to Expanded FMLA (EFMLA) in accordance with the Families First Coronavirus Response Act (FFCRA) if the employee satisfies eligibility standards. Employees can complete this form and submit it or any questions to ▇▇▇.▇▇▇▇▇@▇▇▇▇▇▇▇▇▇.▇▇▇ Employee Name: Mailing Address: E-mail: Home Phone Number: Alternate Phone Number: Employment Start Date: Employees must have worked for the District for 30 days to be eligible for EFMLA. Expected Begin Date of Leave: Expected Return to Work Date: Employees satisfying the standards noted below are eligible for 12 weeks* of leave. The first two weeks of the leave are unpaid unless the employee selects available options in the next box. The remaining 10 weeks of leave are paid at 2/3 of the employee’s regular compensation rate unless other options are selected on this form. Please select the applicable reason and follow the applicable instructions. □ I am unable to work or telework because I need to care for my child under age 18 because my child’s elementary or secondary school, childcare provider, or child’s place of care has been closed or is unavailable due to a public health emergency. During this period of unavailability or closure, I represent that no other person will be providing care for my child during the period for which I am receiving EFMLA. Name(s) and Age(s) of Child/Children: The name of the school, place of care, or child care provider that closed or became unavailable due to COVID-19 reasons. If the age of one or more of your children is between 14 and 18, the following special circumstances exist requiring me to care for the child during daylight hours:

For District Use Only. Request Received By: Date: Leave Approved By: Date: Period of Leave: Duration and Type of Substituted Leave for First Ten Days Approved: If you believe you are at increased risk of severe illness from COVID-19 due to a certain underlying health conditions (as that term is defined by the Center of Disease Control (CDC); ▇▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/coronavirus/2019-ncov/need-extra- precautions/people-with-medical-conditions.html and the Governor’s proclamation 20-46, amended; ▇▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇.▇▇.▇▇▇/sites/default/files/20-46%20-%20COVID- 19%20High%20Risk%20Employees.pdf?utm_source=▇▇▇▇▇▇▇▇.▇▇▇) or reside with someone who will be at increased risk (as that term is defined by the CDC and the Governor’s proclamation 20-46, amended), we will need verification from your healthcare provider or the healthcare provider for the person(s) with whom you reside. The risk for exposure is case by case, and depends both on your individual health considerations as well as the specifics of your job. After consulting with your healthcare provider, please have them fill out and sign the form below. This form may be submitted electronically to: ▇▇▇▇▇▇▇.▇▇▇▇▇▇▇▇▇▇▇@▇▇▇▇▇▇▇▇▇.▇▇▇, fax to: ▇▇▇-▇▇▇-▇▇▇▇ or mail to:  CDC- People with Certain Medical Conditions ▇▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/coronavirus/2019-ncov/need-extra- precautions/people-with-medical-conditions.html  State of Washington – Proclamation by the Governor Amending Proclamation 20-05; 20-46 High-Risk Employees – Workers’ Rights ▇▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇.▇▇.▇▇▇/sites/default/files/20-46%20-%20COVID- 19%20High%20Risk%20Employees.pdf?utm_source=▇▇▇▇▇▇▇▇.▇▇▇