APPENDIX K SICK LEAVE DONOR PROGRAM AUTHORIZATION FORM

To be completed by employee or another acting on employees behalf:

Name: ___________________________________________   Title: ___________________________

         (Please print)

Department: ______________________________________   Division: ________________________

Work schedule: Full-time: ___   Part-time: ___    If part-time, how many work hours per week? ________

Work phone: _____________________________   Home phone: ___________________________

Please read the information below. (See Section 17-10 of the Personnel Regulations for more information about the Sick Leave Donor Program.)

1.   If you received a pay advance, as reflected on your payroll check, those advanced hours will be paid off by your initial grant of donated sick leave. This will cause the payroll check containing the initial grant of donated sick leave to be less than a full check. This Finance Department policy was established to prevent any overpayment of salaries beyond the end of the time sheet certification. The Payroll Section will give you further notice of this adjustment before it sends you the affected payroll check. If you have questions about this, please call the Payroll Section, at 240-777-8840.

2.   The Director of the Office of Human Resources may revoke a leave donation to an employee, declare an employee ineligible for leave donations for up to one year, or recommend discipline to the employees department director, if the employee:

   •   gives false or misleading information on a form associated with the Sick Leave Donor Program; or

   •   attempts to intimidate, threaten, or coerce another with respect to donating, receiving, or using sick leave or PTO under the Sick Leave Donor Program

3.   Complete this form, the Sick Leave or PTO Donation Request Form, the Medical Certification Form for Sick Leave or PTO Donations, and send the forms with a copy of the approved leave request (if in written form) to the Payroll Section. Payroll must receive all required forms no later than the Monday following a payday to ensure that you receive a paycheck based on the donated leave on the next payday.

Please fax or send the forms (fax is preferred) to: Payroll Section, Attention: Sick Leave Donor Program, 101 Monroe Street, 8th Floor, Rockville, Maryland 20850. (FAX [phone] and phone [phone])

Signature of employee or

person signing for employee: __________________________________ Date: ___________________

If employee did not sign form, please indicate below your relationship to employee and phone number(s) where you may be reached:

______ _____________________________________________________________________________________________

SICK LEAVE DONOR PROGRAM AUTHORIZATION FORM

To be completed by employees Department Director or designee:

Name of employee requesting sick leave or PTO donations:__________________________________

Please answer the questions below.

1.   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 employees position for more than 7 consecutive calendar days?   ( ) Yes ( ) No

2.   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.) *Editors note—see 33.07.01.10

3.   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

4.   Has the employee provided a completed Medical Certification Form for Sick Leave or PTO Donations or a written statement from the employees health care provider that supports the request for sick leave or PTO donations? (Please attach the medical certification.)         ( ) Yes ( ) No

5.   Has the employees 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 _____

6.   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 employees paid leave and is on leave without pay, please be sure to notify OHRs Records Management unit at 240-777-5112.

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

SICK LEAVE DONOR PROGRAM AUTHORIZATION FORM

To be completed by employees Department Director or designee:

Employees Name: ________________________________________________

Date received: ____________________________________________________

1.   A full-time employee who donates leave must maintain a sick leave or PTO balance of 80 hours after donation. A part-time employee who works at least 40 hours in a pay period must maintain a sick leave or PTO balance of 40 hours. A part-time employee who works less than 40 hours in a pay period must maintain a pro-rated amount of unused sick leave or PTO after donation.

2.   Employee recipient leave balance:

   Annual _____   Sick _____   PTO _____   Personal leave days _____   Compensatory time _____

3.   To be eligible to receive donated sick leave or PTO, an employee must have an extended illness or injury that causes the employee to be unable to work for more than 7 consecutive calendar days.

   Employees last day worked: __________________________________

4.   Date employee exhausted all paid leave: _______________________________

5.   A full-time employee may receive up to 1040 hours of donated leave in a leave year. A part-time employee may receive a prorated amount of donated leave.

   Total leave donated to employee: ______________________________

6.   To be retroactive: ( ) Yes ( ) No

Authorized by: ____________________________________   Date: __________________________