TEMPORARY SHARED LEAVE DONATION FORM – SCHOOL CLOSURE
I _______________________________ volunteer to donate ______hours of _______________
(employee name - printed/employee #) (leave type)
leave to_________________________________________ effective _______________.
(employee name - printed/employee #) (date)
• I understand that I am donating leave for school closing. (Leave type can only be sick, vacation, stand by comp.,
COVID)
• I understand that the leave will not be repaid by the above referenced employee.
• I understand that the amount of leave I have chosen to donate is not available for my use after the
effective date indicated on this form.
• I understand that the City is not responsible for any future need for leave I may have as a result of this
donation.
• This leave is not compensable (counted toward overtime payment) for the receiving employee. Leave
donations are not tax deductible.
I have read, understand and agree to the policy guidelines. I confirm all information is
provided voluntarily and is true and correct.
_________________________ _____________________
Employee signature Date
____________________________________________________
DEPARTMENT DIRECTOR CERTIFICATION
____ I certify that this employee has the leave required and has a balance of at least 40 hours of leave
between all eligible leave types remaining after donation.
____ Temporary shared leave donation not approved.
Reason________________________________________________________________________________
______________________________________________________________________________________
_ _________________________________ _______________
Department Director signature Date
__________________________________________________________
HUMAN RESOURCES DEPARTMENT RECEIPT Date received_____________ Initials of HR Rep________
Temporary shared leave credited to the requesting employee’s time: # of hours:_______________
Leave type debited from the donating employee’s time _________________ # of hours: ______________
Unused donated leave type __________________ # of hours _____________ Reason:________________
_______________________________________________________________________________________
_____Returned to donor’s timekeeper Date: ______________
NOTE TO TIMEKEEPER – Paycodes: [318-Temp. shared leave] [319-Temp. shared leave PT ] [377 FMLA-Temp. shared leave]
[378-FMLA Temp. shared Leave PT]
Original form to HR Connect; Copy to employee and Employee’s Department
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