SET Qualify

First Name

Last Name

Email

Phone

Company website

April 1, 2020 – March 31, 2021

April 1, 2020 – March 31, 2021

Sick Leave

Yes

No

How many days were you unable to work related to your covid diagnoses?

Please list the dates you were out of work.

Family Leave

Yes

No

How many days did you miss work to care for that child?

Please list the dates you were out of work.

Did you miss work to care for a child that was unable to attend school due to covid shutdowns?

Yes

No

How many days did you miss to care for the child during remote learning?

Please list the dates you were out of work.

April 1, 2021 – September 30, 2021

April 1, 2021 – September 30, 2021

Sick Leave ( Did you miss work due to Covid in 2020? )

Yes

No

How many days were you unable to work related to your covid diagnoses?

Please list the dates you were out of work.

Family Leave ( Did your child have Covid in 2021? )

Yes

No

How many days did you miss work to care for your child?

Did you miss work to care for a child that was unable to attend school due to covid shutdowns?

Yes

No

How many days did you miss to care for the child during remote learning?

Please list the dates you were out of work.