Form Hr-100 - Donation For Catastrophic Illness Leave - 2011
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1DONATION FOR CATASTROPHIC ILLNESS LEAVE
To be eligible to donate vacation leave:
1. Time can be donated in 4 hour increments.
2. You must not have solicited nor accepted anything of value in exchange for the donation.
3. You must have remaining to your credit at least 40 hours of accrued vacation leave.
Please note that Rules and Regulations covered employees can only donate vacation time whereas employees
under the Labor Contract can donate vacation time as well as accumulated comp time.
Name of Employee you are donating to: ______________________________________________________
Type of donation: Vacation time Comp time (contract covered only)
Number of hours donated (must be 4 or over): _________________ hours
I understand my vacation leave or comp time balance will be decreased by the number of hours I am donating
and that my vacation or comp time leave shall be irrevocably credited to the recipient’s sick leave account.
Your Signature ___________________________________________________ Date __________________
Please print your name ____________________________________________________________________
Your Employee ID Number ________________________________________________________________
Your Office Location ______________________________________________________________________
I authorize release of my name and hours donated to recipient only upon request. Yes
No
Witness Signature _______________________________________________________________________
Supervisor’s Name/Location ________________________________________________________________
Human Resources & Development Use Only
Eligible
Position No. __________________________________
Ineligible
Hourly Rate of Donor ___________________________
Reason: __________________________
Verified by HR&D contact _____________________________________
__________________________________
Name
Date
Original sent to requester HR&D contact __________________________
__________________________________
Date
Donated Hours Used _________________*
(*All of donated hours may not be used if requested amount has been met and remaining
Notice sent to Donor _________________
hours would exceed request.)
Date
Verified by __________________________________________________
Human Resource & Development Contact
Date
Copy sent to donor HR&D contact _______________________________
Name
Date
Notice sent to Donor of hours used _______________________________
Date
HR-100 3/11 (10044)
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