Iredell Countyapplication to Receive Voluntary Shared Leave

Iredell CountyApplication to Receive Voluntary Shared Leave

Instructions: Please complete the information below and submit this form to your supervisor along with a medical certification from your treating physician documenting the need for leave and the period of absence. (Medical forms can be downloaded from IredellCounty’s Intranet or obtained from HR. If FMLA medical certification has already been submitted at the time of this request, an additional certification is not necessary).

Employee Name ______Department ______

Annual Leave Balance ______Sick Leave Balance ______Compensatory/HOL Balance ______As of Date: ______

TOTAL NUMBER OF LEAVE HOURS REQUESTED: ______(Minimum hours requested 160 to maximum 480 hours) medical certification must support requested hours)

Please attach a brief explanation for why you are requesting shared leave and why you do not have adequate leave balances to cover your time away from work.

Employee Statement:

“This is to request participation in IredellCounty’s Shared Leave Program. The need for leave is necessitated by my own medical condition or by my immediate family member’s medical conditionas certified by the attached physician’s statement. I am not receiving Worker’s Compensation benefits and I anticipate a leave of absence of at least 160consecutive work hours due to this condition. All of my accrued paid leave will be exhausted, and I am requesting donated Shared Leave hours as specified above.”

Initial applicable authorization (PLEASE READ)

_____ I authorize Human Resources to solicit donations on my behalf in the event there is not enough time in the Shared Leave Bank to accommodate my request. Human Resources may release mypersonal identification indicating that Ihave been approved for and request shared leave donations.

_____ I do not authorize Human Resources to release my personal identification for requested shared leave donations. I understand this may adversely impact the number of approved hours for which I may otherwise be eligible.

If I am approved for shared leave, I have read and agree to comply with the Shared Leave Policy as described on the County website at Munis Self Serve or a copy will be provided to me at my request.

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Employee’s Signature Date

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Date Received from employee ______I recommend Approval ______

I do not recommend approval because:______

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Department Head Signature (Forward to HR)Date

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Employee meets _____ does not meet ______eligibility requirements for participation in the Shared Leave Program.

Reason for not meeting Requirements: ______.

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Human Resources Director(Forward to CountyMgr)Date

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Request for Shared Leave is approved _____ denied ______Additional information is needed ______

Reason not approved: ______

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County Manager Signature (Forward to HR)Date

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TO BE COMPLETED BY HR:

Hourly Rate ______# Hours ______Total Value ______

Transfer completed by: ______Date:______

Revised Date: 7/1/11