Laserfiche WebLink
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 />* * * * * * * * * * <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 />39 <br />