Short Term Disability Application for COVID-19

Princeton University Application for Short Term Disability Benefits for COVID-19 Condition

Faculty and staff who are diagnosed with COVID-19 or presumed positive by a healthcare provider can apply for short term disability benefits by completing this newly created form that simplifies and expedites the review and approval process.

The HR Benefits Team will not accept a COVID-19 Short Term Disability Application that provides a University Health Services contact or physician, i.e. a healthcare provider from Occupational Health or Global & Community Health Departments, under Name of Physician. It is expected that employees will consult with their primary care provider or other medical professional regarding their diagnosis, just as with any other disability absence.

For any questions, email the HR Benefits Team or call (609) 258-3302.

Last Day Worked
Provide the following information regarding the healthcare provider who is treating you for this disability:
As stated above, this must be a physician outside of the University Health Services community.

Certification and Electronic Signature:

This form is to be used only for employees in the following circumstances (a) you are diagnosed with COVID-19; (b) you are presumed positive or have been tested for COVID-19. Read the statements below, check each box, and electronically sign to verify accuracy of these statement.

Electronic Signature