San Juan School District

Sick Leave Donation Form (Compassionate Leave Transfer)

District Sick Leave Assistance Program

Part I – DonatingEmployee’s Information
Name: / Date:
Position: / School:
Name of Individual to Receive Donation: / Number of Days/Hours Donated:
Purpose of the District Sick Leave Assistance Program: The Sick Leave Assistance Program is established to provide a process whereby employees may donate eligible sick leave to other employees whose leave benefits have exhausted but who need to be absent from work for an extended time because they have a serious chronic illness or because they (or an immediate family member) have suffered a catastrophic illness or injury.
Purpose of the Sick Leave Donation Form (Compassionate Leave Transfer) form: To allow a qualifying employee to donate up to five days per year to a specific employee who has experienced a catastrophic illness or injury.
Eligibility: All classified employees who have more the 80 hours of sick leave and all licensed and administrative personnel who have more than 10 days of sick leave.
Part II – General Information
In order for an employee to receive donated sick leave, the Human Resources Office will establish that an employee has met all conditions and that a request for donated leave exists. For this to happen, all of the following conditions must be met:
-The employee illness or injury is catastrophic or chronic and is confirmed in writing by a physician chosen by the employee but subject to reconfirmation by the district physician if necessary.
-The employee has exhausted all forms of paid leave (e.g., sick leave, personal leave, vacation leave, and compensatory time).
-The employee is unable to perform the essential functions of his or her job held at the time of the illness or injury.
-The employee is not on probationary status.
Agreement: In accordance with the District’s Sick Leave Assistance Program, District Policy 4150.15, I voluntarily agree to donate thenumber of hours or days of sick leave to the individual as listed in Part I of this form. I understand that once this form is submitted and approved, the leave transfer will be permanent. I understand that if any leave is not used, it will be returned to my leave balance. I understand that this will be credited as leave used for the year. For Licensed employees, I understand that this donation will reduce the amount paid in the annual end of year sick leave bonus that is paid.
______
Requesting Employee’s Signature Date
Part III – Approval
I have reviewed this Sick Leave Donation Form and recommend that it be approved. The employee meets the criteria for donating sick leave and understands the policy.
______
Signature of Principal or Supervisor Date
Human Resources Approval: ______Approved ______Disapproved with Reason: ______
______
Signature of Human Resources Director (or Assistant) Date

HR Form 4150.5 - 2