FMLA for Employee
Rev. 6/2017
Request for Donated Sick Leave for Catastrophic Illness or Injury Must Complete a New Form for each 20 Day Block Name of Employee Requesting Donated Leave
Date
Site Nature of Illness or Injury Attach Attending Physician’s Statement Number of Leave Days Requested (up to 20 per form) Yes, I want my name shared with the ACT/MDSEA President Sick Leave Donation Procedures: If an employee has exhausted or will exhaust all earned accumulated sick leave otherwise provided, and is absent due to an extraordinary or severe illness, impairment or physical or mental condition of the employee, a relative or household member, documented as such by a physician, including temporary disability resulting from pregnancy, miscarriage, childbirth, and recovery therefrom, and the condition has caused or is likely to cause the employee to take leave without pay or to terminate employment, the employee, or the employee’s caregiver, may request the use of sick leave days to be donated by other employees. The employee may solicit these days on his/her own behalf. In order to efficiently process requests for donated leave employees should initiate a request as soon as the need arises. Employees must request leave before their own leave and/or donated leave is exhausted. Employees may not request leave to be back-dated. 1.
Relative means a spouse, child, stepchild, grandchild, grandparent, stepparent or parent. Household member means one who resides in the same house as the employee and who shares a duty to provide financial support with the employee, or any other person(s) as designated by law.
2.
An employee may initially request up to twenty (20) days from donating employees. If needed, the employee may reapply to receive sick leave days beyond the first twenty (20) to be three (3) additional twenty (20) day periods for a total of eighty (80) days within the current school year. The Superintendent may grant an extension beyond the 80 day limit in extenuating circumstances. (Board Policy G: 9)
3.
An employee requesting donated days must first provide the Board with a medical certificate from a licensed physician or health care provider verifying the severe or extraordinary nature and expected duration of the condition. Documentation by a physician is required for each requested twenty (20) day period. The employee receiving donated days is to receive his or her normal rate of pay.
4.
Shared sick leave usage records shall be maintained separately from regular sick leave records.
5. The Board is the determining body as to whether the employee meets the criteria above and has previously abided by District leave policy. I understand and have received a copy of this form ___________________________ Signature
__________ Date
Refer to complete Sick Leave Donation Policy in your negotiated contract.
______________________________________ Dr. Jason Perez, Chief Human Resources Officer
________________________________________ Dr. Rick Cobb, Superintendent
___________________ Date
____________________ Date
Request for Donated Sick Leave for Catastrophic Illness or Injury Must Complete a New Form for each 20 Day Block Name of Employee Requesting Donated Leave
Date
Site Nature of Illness or Injury Attach Attending Physician’s Statement Number of Leave Days Requested (up to 20 per form) Yes, I want my name shared with the ACT/MDSEA President Sick Leave Donation Procedures: If an employee has exhausted or will exhaust all earned accumulated sick leave otherwise provided, and is absent due to an extraordinary or severe illness, impairment or physical or mental condition of the employee, a relative or household member, documented as such by a physician, including temporary disability resulting from pregnancy, miscarriage, childbirth, and recovery therefrom, and the condition has caused or is likely to cause the employee to take leave without pay or to terminate employment, the employee, or the employee’s caregiver, may request the use of sick leave days to be donated by other employees. The employee may solicit these days on his/her own behalf. In order to efficiently process requests for donated leave employees should initiate a request as soon as the need arises. Employees must request leave before their own leave and/or donated leave is exhausted. Employees may not request leave to be back-dated. 1.
Relative means a spouse, child, stepchild, grandchild, grandparent, stepparent or parent. Household member means one who resides in the same house as the employee and who shares a duty to provide financial support with the employee, or any other person(s) as designated by law.
2.
An employee may initially request up to twenty (20) days from donating employees. If needed, the employee may reapply to receive sick leave days beyond the first twenty (20) to be three (3) additional twenty (20) day periods for a total of eighty (80) days within the current school year. The Superintendent may grant an extension beyond the 80 day limit in extenuating circumstances. (Board Policy G: 9)
3.
An employee requesting donated days must first provide the Board with a medical certificate from a licensed physician or health care provider verifying the severe or extraordinary nature and expected duration of the condition. Documentation by a physician is required for each requested twenty (20) day period. The employee receiving donated days is to receive his or her normal rate of pay.
4.
Shared sick leave usage records shall be maintained separately from regular sick leave records.
5. The Board is the determining body as to whether the employee meets the criteria above and has previously abided by District leave policy. I understand and have received a copy of this form ___________________________ Signature
__________ Date
Refer to complete Sick Leave Donation Policy in your negotiated contract.
______________________________________ Dr. Jason Perez, Chief Human Resources Officer
________________________________________ Dr. Rick Cobb, Superintendent
___________________ Date
____________________ Date
