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

Last Day Worked
Provide the following information regarding the health care provider who is treating you for this disability:

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