Submit this form along with the necessary documentation through your employer's HR department. You can also fax the completed form to the HR department or submit it via their online submission platform. If physical submission is required, mail it to the employer's physical address.

For the years 2024 and 2025, note any guidance issued at the beginning of the year, along with any mid-year updates related to COVID-19 benefits and documentation requirements.

This form is necessary to document various scenarios related to COVID-19 that impact employee work status. It helps employees and employers manage time off, benefits, and disability claims due to COVID-19. The accurate filling of this form ensures proper documentation and compliance with federal, state, and Kaiser Permanente guidelines.

• 1. Medical Scenario: Specify the medical situation affecting the employee.
• 2. Documentation: Mention the type of documentation required for the scenario.
• 3. How to Obtain Documentation: Instructions on how to get the necessary documentation.
• 4. Submission: Guidelines for submitting the documentation to employers or administrators.

Failure to submit this form can result in delays in receiving benefits and approval of leave. It can also impact compliance with state and employer requirements.

• Delayed Benefits: Processing of benefits may be delayed without proper documentation.
• Denial of Leave: Failure to submit can lead to denial of leave requests related to COVID-19.
• Compliance Issues: Non-compliance with employer and state guidelines may occur.

• 1. Symptomatic Employee: When the employee has symptoms and cannot work.
• 2. High-Risk Employee: When the employee has preexisting conditions that put them at risk.
• 3. Exposure: When the employee needs to self-isolate due to exposure.
• 4. Caregiving: When the employee needs to care for a sick or high-risk family member.
• 5. State or Private Disability Claims: When filing a disability claim related to COVID-19.