Fill and Sign the Shared Leave Request Form

SHARED LEAVE PROGRAM – REQUEST FORM Employee Name:       Social Security Number:       Position:       Date of Hire:       Estimated Length of Disability:       Amount of Leave (hours) Requested:       (Maximum 174 hours) Description of Medical Condition – (Attach supporting documentation) RECIPIENT GUIDELINES : A. A prospective recipient may make application for voluntary shared leave at such time as medical evidence is available to support the need of leave beyond the employee’s available accumulated leave. Applications for shared leave are available in Human Resources. B. Participation in this program is limited to 174 hours during any consecutive 12 month period. This benefit shall be for all full-time employees, granted on a month-by-month basis by management, either continuously or, if for the same condition, on a recurring basis if management would have otherwise granted leave without pay. C. The employee must exhaust all available earned leave, both paid and unpaid, before using donated leave. D. At the expiration of the medical condition, as determined by the company, any unused donated leave in the recipient’s donated leave account in excess of 40 hours shall be returned to the donor(s) on a pro rata basis and credited to the leave account from which it was donated. Fractions of an hour shall not be returned to an individual donor. E. If a recipient separates from the company or provides notice of intent to separate due to resignation, death, or retirement, participation in the program ends. Donated leave shall be returned to donor(s) on a pro rata basis. CONSENT FORM : I,       _______ , hereby request permission to participate in the Shared Leave Program and am willing to have my disability or medical condition made known to other employees in an attempt to receive shared leave. I fully understand that such a disclosure could result in the release of information considered confidential that is normally not disclosed to the general public. I further understand that transfer of leave is strictly voluntary and I am not to solicit leave from fellow employees. _____________________________________ Date: _________ Employee’s Signature DATE RECEIVED: _________ APPROVED BY: __________________________