Sick Leave Donation Request Form

GCCG-EA
PROFESSIONAL / SUPPORT STAFF VOLUNTARY TRANSFER OF ACCRUED SICK LEAVE
REQUEST FORM
The following is to be completed and submitted to the payroll secretary prior to using any donated sick leave days. The payroll secretary will forward the request to the Voluntary Sick Leave Donation Program Committee for their action.

The Voluntary Sick Leave Donation Program was established to assist all District employees in dealing with a non-job related illness or injury, seriously incapacitating, an extended health situation of their own or of a close family member as verified by a licensed health care practitioner. These may include such things as complications from major surgery, serious injury due to accidents, and/or life threatening illnesses. The intent is to provide some measure of relief in such circumstances. For purposes of the Voluntary Sick Leave Donation, family shall include:
Spouse Grandparents

Children Grandchildren

Parents Father and Mother-in-law

Brothers and Sisters Sons and daughters-in-law

Spouse's brothers and sisters
Employees Name*
Employee Email*
example@example.com
Department*
Dates and number of donated days requested (cannot exceed sixty (60) days, six (6) hours equal one (1) day for certificated staff
Dates*

MonthDayYear
Total Days Requested*
I verify I have met all of the following conditions:

A. I have exhausted all of my accrued sick leave.

B. I will not have used more than sixty (60) donated sick leave days for the fiscal year.

C. I am not entitled to receive workmen's compensation or government disability benefits.

D. Provide supporting medical documentation.

E. Days requested will be used in compliance with District Sick Leave Policy.

F. Give permission for this information to be submitted to staff to seek donors.
Expected date for return to duty*

MonthDayYear
Please provide a narrative explaining the reason for this request and how it meets policy GCCG Sick Leave Donation Program This is part of the policy and helps the committee make the best decision
Signature
Date

MonthDayYear
Who may we request to Witness this form?*

First NameLast Name
Witness Email
example@example.com
Total Number of days donated
@ hours per day
Should be Empty:

GCCG-EA

PROFESSIONAL / SUPPORT STAFF VOLUNTARY TRANSFER OF ACCRUED SICK LEAVE

REQUEST FORM