Request to Use Donated Sick Leave
Your Name
*
First Name
Last Name
Email
*
example@example.com
Department:
*
Manager's Name
*
First Name
Last Name
Manager's Email:
*
example@example.com
Please state below the number of hours of sick leave requested from the medical emergency sick leave bank.
*
I understand:
I may not receive more than 480 hours (12 weeks) of donated sick time within a rolling 12-month period
Per IRS guidelines, donated leave is considered income and is therefore taxable to me
Someone from HR will be reaching out to me to discuss, verify and approve or deny my request for donated sick leave
Signature
*
Date
*
-
Month
-
Day
Year
Submit
Should be Empty: