Equal Employment Opportunity (Eeo) Policy And Program Administration Form Sample Page 38
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54VA MEDICAL CENTER
POLICY MEMORANDUM 00-304
BRONX, NEW YORK 10468
July 31, 2003
ATTACHMENT 2
LEAVE TRANSFER AUTHORIZATION
Department of Veterans Affairs
INSTRUCTIONS: Complete Part 1 and submit the form to your Human Resources Management Office.
PART I - TO BE COMPLETED BY LEAVE DONOR
NAME OF DONOR (Last, First, M.I.)
ORGANIZATION UNIT
GRADE (Include step)
SALARY RATE
$
NAME OF RECIPENT OF DONATED LEAVE
AMOUNT OF DONATED LEAVE
HOURS/DATES OF REGULAR ANNUAL LEAVE
HOURS/DAYS OF RESTORED ANNUAL LEAVE
SIGNATURE OF DONOR
DATE SIGNED
AUTHORIZATION - I authorize transfer
of leave to the above-named recipient.
PART II - ACTION BY HUMAN RESOURCES MANAGEMENT OFFICE
I have reviewed the current position and the grade pay levels of the above-named donor and leave recipient and certify that this request
meets
does not meet the administrative requirement for leave transfer.
COMMENTS
SIGNATURE
TITLE
DATE SIGNED
PART III - ACTION BY PAYROLL OFFICE
I have reviewed the leave record of the above-named donor and certify that the annual leave in the amount shown below meets the criteria of the leave
transfer program. This leave is transferred on the date indicated below.
AMOUNT OF LEAVE
EFFECTIVE DATE
HOURS/DAYS
COMMENTS
SIGNATURE
TITLE
DATE SIGNED
PART IV - ACTION BY PAYROLL OFFICE AT ERMINATION OF THE PERSONAL EMERGENCY
DATE PERSONAL EMERGENCY ENDED
HOURS/DAYS OF ANNUAL LEAVE
DATE RESTORED
INITIALS OF PAYROLL CLERK
DATE SIGNED
RESTORED TO DONOR
In Lieu of VA Form 0239
16
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