Updated 4/2019
Shared Sick Leave Bank Donation Form
Name: _________________________ ID#______________ Date____________
The College will maintain a Shared Sick Leave program for employees who are unable to work
due to the employee’s own serious illness, injury or impairment which requires continuing
treatment/supervision by a health care provider and which is likely to cause the employee to
take a prolonged leave without pay or likely to result in a substantial permanent disability
leading to termination of employment or retirement with the College.
An employee may donate up to 40 hours from his/her accrued sick leave in a fiscal year to the
Shared Sick Leave bank as long as his/her accrued sick leave does not fall below 240 hours.
Once a donation has been made to the Shared Sick Leave bank, it cannot be restored to the
individual. Donations may be made during the months of September and May of each year.
You can learn more about the general guidelines, eligibility, approval process, benefits and more
by reviewing the Shared Sick Leave Program Policy 5.37.
I authorize East Central College to deduct ________ hours of sick leave from my accrued sick
leave balance and to transfer these donated hours to the college sick leave bank.
Employee Signature
To be completed by Human Resources:
Employee’s sick leave balance at time of donation ___________
Amount of hours being donated ___________
Hours left in Employee’s sick leave ___________
(Employee sick leave cannot fall below 240 hours at time of donation)
Approved Not Approved
Human Resources Signature/Date
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