PROCEDURES FOR CATASTROPHIC
LEAVE DONATION PROGRAM
CATASTROPHIC LEAVE PROGRAM
INSTRUCTIONS: Employee or designee is to complete Part A, Requestor Information, and attach to this form: a) medical certification from
a physician and b) hold Harmless Agreement, available from Human Resources or Academic Affairs. The completed forms are to be
forwarded as a package to Academic Affairs ( Unit 3 ) or to Human Resources (for all other collective bargaining units).
PART A -- REQUESTOR INFORMATION
Recipient's First Name
Recipient's Last Name
Estimated length of illness:
Estimated amount of
donated sick leave needed:
A copy of the physician's meddical certification, including a
diagnosis/prognosis must be attached
I have applied for:
Nonindustrial Disability Leave
Industrial Disability Leave
I authorize the university to notify the union representative and/or
on my behalf of the status of my certification of eligibility.
Employee/Employee Designee's Signature
PART B -- CERTIFICATION OF ELIGIBILITY
ELIGIBLE -- The above employee meets all the criteria outlined in the respective collective bargaining unit agreement and is
eligible to receive donated
vacation credits only.
all leave credits.
NOT ELIGIBLE -- The above employee dot not meet all the criteria outlined in the respective collective bargaining unit agreement
and is not eligible to receive donated
Staff Unit Employee Relations Designee
Unit 3 Employee Relations Designee