Leave Pool Donation Form
05/01/2012
Page 1 of 1
Crisis Leave Pool Donation Form
This form is used by employees to donate unused annual leave to the crisis leave pool.
Employee Name CWID
Mailing Address
Number of hours donated
(note must be a minimum of 4 hours, not to exceed 240 hours - whole hour increments only)
No employee can donate unless they will have a remaining balance of 120 hours.
Please check if leaving employment at BPCC. Donations at separation/retirement
are limited to 120 hours.
Yes
No
I, the undersigned employee, voluntarily, without coercion or pressure, donate the specified hours listed above of my
earned annual leave. I understand that the voluntary donation is irrevocable and will reduce my annual leave balance
by the number of hours stated. I understand that my identity as a donor will be kept confidential. I understand that I
may not stipulate who is to receive the donation of leave.
______________________________________________________ ________________________________
Employee Signature Date
* If your donation is not approved in whole or in part, a memo of explanation will be returned to you with this form.
______________________________________________________
________________________________
Approval *: Date
Human Resources Department
I am (check on that applies): Unclassifed Classified in permanent status.
This donation to crisis leave form must be submitted to the Leave Pool Manager, Human Resource Department.
Human Resource Office contact Information - Telephone 318-678-6040, Fax 318-678-6411
