Revised November 2016
Voluntary Shared Leave Donation
Recipient Name
Donor Name ______________________________________Donor ID________________________
Donor Department
Donor Telephone Numbers: Work ___________________ Cell __________________________
Donor E-mail
Donor Signature __________________________________________________________________________
Permanent, leave-earning employees may donate their leave time to employees who have been
approved to receive Voluntary Shared Leave (donated leave time) due to a medical condition of the
employee or his/her immediate family member which will require the employee’s absence from work
for an extended period of time.
Donor must have available leave time to donate and the maximum amount of vacation
leave that may be donated may not be more than the amount of the donor’s annual accrual
rate and may not reduce the donor’s vacation leave balance below one-half of the annual
vacation leave accrual rate. Sick leave maximum may not reduce the donor’s sick leave
account below 40 hours.
When meeting donor eligibility stated above:
Non-Family Members of the recipient can donate a maximum of 40 hours Sick Leave or unlimited
vacation or Vacation Bonus Leave hours.
Immediate Family Members can donate unlimited Sick Leave hours as well as unlimited Vacation or
Vacation Bonus Leave.
Please fill in the number of hours you wish to donate in the appropriate box or boxes below. You may
donate in more than one category.
Vacation Vacation Bonus (VABO) Sick
Please check one of the following boxes pertaining to your relationship with the recipient.
Non-Family Member Immediate Family Member
ADVISORY NOTE: Donation of Sick Leave could affect your retirement. At retirement, a member of the
Teachers’ and State Employees Retirement System (TSERS) with an earned Sick Leave balance receives an
additional month of service credit for each 20 days or portion thereof. The additional service credit
increases the retirement benefits for the remainder of the life of the retiree.
Questions regarding FMLA or Voluntary Shared Leave, contact Ext. 6488.
Return this form to Carolyn Bosley, Human Resources, or e-mail
HR Approval Date
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