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SICK LEAVE DONATIONS REQUEST FORM <br />Name of Employee: Dept./Division: <br />Position Title: <br />Date Absence Began or Will Begin: <br />Expected Date of Return: <br />*Specify duration of treatment regimen for intermittent absences (Ex: 1 day per week for 12 <br />weeks): <br />Authorized by Department Head: Date <br />To be completed by Human Resources <br />Has the employee provided the Human Resources Department with a completed "Certification <br />of Health Care Provider" form? (Requests for sick leave donations cannot be processed until <br />Human Resources has this information.) Yes No <br />Based on the Sick Leave Donations Policy, is the employee eligible to receive sick leave <br />donations? Yes No If no, state reason: <br />Human Resources Director Date <br />"Donations for Intermittent Leave Must Have Approval by County Administrator: <br />Signature Date <br />35 <br />SECTION <br />NUMBER <br />EFFECTIVE DATE <br />ADMINISTRATIVE <br />HUMAN <br />POLICY <br />RESOURCES <br />AM -704.1 <br />1/21/2020 <br />MANUAL <br />SUBJECT <br />PAGE <br />SICK LEAVE DONATION <br />4 of 4 <br />SICK LEAVE DONATIONS REQUEST FORM <br />Name of Employee: Dept./Division: <br />Position Title: <br />Date Absence Began or Will Begin: <br />Expected Date of Return: <br />*Specify duration of treatment regimen for intermittent absences (Ex: 1 day per week for 12 <br />weeks): <br />Authorized by Department Head: Date <br />To be completed by Human Resources <br />Has the employee provided the Human Resources Department with a completed "Certification <br />of Health Care Provider" form? (Requests for sick leave donations cannot be processed until <br />Human Resources has this information.) Yes No <br />Based on the Sick Leave Donations Policy, is the employee eligible to receive sick leave <br />donations? Yes No If no, state reason: <br />Human Resources Director Date <br />"Donations for Intermittent Leave Must Have Approval by County Administrator: <br />Signature Date <br />35 <br />