Mcpr 2001 Appendix K Sick Leave Donor Authorization Form (Page 2 of 3) in pdf

MCPR, 2001

APPENDIX K, SICK LEAVE DONOR PROGRAM AUTHORIZATION FORM

Sick Leave Donor Program Authorization Form

To be completed by employee’s Department Director or designee

Name of employee requesting sick leave or PTO donations: _________________________

Please answer the questions below.

Has the employee had an extended illness or injury, which may include complications of

pregnancy or childbirth or recovery from childbirth, that causes the employee to be

unable to perform the essential functions of the employee’s position for more than 7

consecutive calendar days?

( ) Yes ( ) No

Has the employee been a County merit system employee for at least 12 consecutive

months?

( ) Yes ( ) No

(If the answer is “no” to either of the questions above, you may ask the Director of the

Office of Human Resources to waive the requirement if special circumstances exist that

would justify a waiver. See Section 17-10 of the Personnel Regulations for more detail.)

Has the employee requested approval to use sick leave or PTO under established

department procedures or practices because of the extended illness or injury referred to

in Question #1?

( ) Yes ( ) No

Has the employee provided a completed Medical Certification Form for Sick Leave or

PTO Donations or a written statement from the employee’s health care provider that

supports the request for sick leave or PTO donations? (Please attach the medical

certification.)

( ) Yes ( ) No

Has the employee’s request to use sick leave or PTO been approved?

( ) Yes ( ) No

If “yes”, the leave was requested and approved by: Leave Request Form____ e-mail ___

Memo ____ verbal ____

Has the employee used, or will the employee have used, all accrued annual leave, sick

leave, personal leave days, and compensatory time or, if the employee receives PTO

instead of annual and sick leave, all accrued PTO, personal leave days, and

compensatory time?

( ) Yes ( ) No

Questions 3-6 above must be answered “yes” in order for the employee to be eligible to receive

sick leave or PTO donations. Questions 1 and 2 must be answered “yes” unless a waiver is

approved by the OHR Director. If the employee has used all of the employee’s paid leave and is

on leave without pay, please be sure to notify OHR’s Records Management unit at 240-777-

5112.

I certify that the employee is eligible for sick leave or PTO donations. I have attached the

employee’s approved leave request (if in written form), Medical Certification Form for Sick

Leave or PTO, and the Sick Leave or PTO Donation Request Form.

Name of Department Director (or designee): ______________________________________

(Please print)

Signature: _____________________________________ Date: ________________________

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Mcpr 2001 Appendix K Sick Leave Donor Authorization Form Page 2

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