Request To Receive Catastrophic Leave-Business Center North-Nevada System Of Higher Education Form printable pdf download

Nevada System of Higher Education

BUSINESS CENTER NORTH

REQUEST TO TRANSFER CATASTROPHIC (CAT) LEAVE

Section 1 -To be completed by the employee or designated representative (please print or type)

Name: ____________________________________

Employee ID# _______________________________

Job Title: _________________________________

Department: _________________________________

Campus (circle one)

Sys Admin

DRI

GBC

TMCC

UNR

WNC

I request a transfer of leave from my account to the Catastrophic Leave Account as noted below:

Number of hours of SICK LEAVE 1) From my regular account: ________ 2) From my banked sick leave: _________

b. Number of hours of ANNUAL LEAVE _________

c. Leave transferred as follows: ______hours to the general CAT Leave Account AND/OR _____hours to the CAT Leave for:

Recipient’s Name _____________________________________________________

Department or State Agency _____________________________________________

I authorize release of my name to the employee that receives the catastrophic leave donation that I have made.

 Yes

 No

Donations must be in increments of 8 hours up to the maximum allowable donation of 120 hours per calendar year. Donor sick leave

balance cannot fall below 240 hours. To the best of my knowledge, I have sufficient leave balances to make this donation.

Donor’s Signature: __________________________________________________

Date: ______________

DONOR: In accordance with NRS 284.3621, leave transferred in excess of the amount approved for use or needed by a particular employee must be returned

to the employee’s account from which it originated. By signing below I authorize any excess hours not used by the recipient to be transferred to the General

Catastrophic Leave Account. Do not sign this section if you wish the hours not used by the intended recipient to be returned to you.

Donor’s Signature: __________________________________________________

Date: ______________

Section 2 – To be completed by Department Leave Record Keeper, Supervisor and Appointing Authority

Department Leave Record Keeper: _______hours sick leave deducted ________hours annual leave deducted

Print Name: _____________________________________________Signature__________________________Date_____________



Supervisor Name: _______________________________________Leave donation approved

Yes

Signature: ______________________________________________________Date_________________________



Appointing Authority Name: _____________________________ Leave donation approved

Yes

Signature: ______________________________________________________Date_________________________

RETURN ALL COPIES OF FORMS TO YOUR CAMPUS HUMAN RESOURCES DEPARTMENT (Form CAT-2 and CAT-3)

Section III - To be completed by Campus Human Resources Department

_______hours transferred to the specific employee _______hours returned to the donor’s account ______hours transferred to the

general CAT Leave Account

Name and Signature: ________________________________________________________Date______________________

Form – CAT -2

BCN Benefits

Request To Receive Catastrophic Leave-Business Center North-Nevada System Of Higher Education Form

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