University of Central Missouri
Crisis Leave Pool Donation Form
F:\HRFORMS\2003 Crisis Leave Donation form.doc
Employee Information:
Name (please print): ________________________________ S
SN or Banner ID: __________________
Department: ___________________________________ Job Title: ____________________________
Campus Address: ______________________________ _ Campus Phone: _______________________
I would like to voluntarily donate vacation leave to the Crisis Leave Pool in the following amount:
_____ four (4) hours _____eight (8) hours _____ other, greater than eight(8)
indicate amount*
I understand that the Office of Human Resources will deduct the above specified hours of vacation leave
from my accrued vacation leave records. This donation is completely voluntary and I will not receive any
remuneration of any kind for the donation. I understand that this donation cannot be rescinded at a later
date. Donations will only be allowed once a quarter. Deadlines to donate are: March 10
, June 10
September 10
, and December 10
. All donations of leave time must be received by the deadline to be
accurately reflected in accrual balances. 80 hours or two weeks of vacation must remain in personal
Employee Signature_____________________________________________ Date: _________________
* in four(4) or eight (8) hour increments
For Office of Human Resources use only:
Annual Salary: $_____________ Hourly Amount: $____________
Approved by: ___________________________________________ Date: ____________________
Leave deducted from vacation accruals: _____________ (# of hours)
Remaining vacation hours: __________
Processed by: __________________________________________ Date: ____________________