SHARED LEAVE – GIVE LEAVE TO A UW EMPLOYEE ORGAN DONOR
INSTRUCTIONS: Please Type or Print Clearly and forward to the HR Operations Office that serves your unit. For HR Operations addresses, see last page.
(Medical Center staff route the completed form along with a copy of requesting employee's current Form 220 if used (Official Record of Hours Worked, Leave and Overtime.)
The employee giving leave completes Section I; department completes Section II; HR Operations office completes Section III
Section I – EmployeeGivingLeave(Complete This Section and Forward to Your Department Administrator for Approval)
Enter the information below for the employee who is the leave recipient (organ donor)Last Name: / First Name: / MI: / UW Department where leave recipient works:
Enter Information Below for Employee Giving Leave
Last Name: / First Name: / MI: / UW ID Number: --
Department: / Work Phone: -- / Email:
Note: A leave gift must be at least 4 hours and may not exceed a total of 10 days of leave for each organ donor to whom you wish to give leave.
I voluntarily give the following total leave hours to the employee designated above and request departmental approval. I understand that the leave hours I am giving will be deducted from my current, appropriate leave balance(s) and that any shared leave not used by the receiving employee will be restored to me on a pro rata basis.
Total Leave Hours I Am Giving: Hours (must equal “Total Hours Given” Box below – 80 hour maximum for full time employees – prorated for part time employees)
Signature of Employee Giving Leave ______Date:
Annual Leave
/ Leave Giving Employee Completes / Leave Recorder CompletesLEAVE GIVING EMPLOYEE: Complete this section to give annual leavehours to a UW employee who is an organ donor. Minimum amount you may give is 4 hours. You must retain 80 hours of annual leave (for full time employees) after deducting your gift of leave. The amount of retained leave is prorated for part time employment. For classified staff, you may not donate excess annual leave above the 240 maximum that you would otherwise be unable to use by your anniversary date. / AL Hours to Give / Current AL Hours / AL Balance After Donation
Sick leave
LEAVE GIVING EMPLOYEE: Complete this section to donate sick leave hours to a UW employee who is an organ donor. Minimum amount you may give is 4 hours. You must retain a sick leave balance of at least 176 hours after deducting your gift of leave. / SL Hours to Give / Current SL Hours / SL Balance After DonationPersonal Holiday
LEAVE GIVING EMPLOYEE: Complete this section to donate personal holiday hours to a UW employee who is an organ donor. Minimum amount you may give is 4 hours. Any personal holiday hours given but not used will be restored only if the hours can be returned within the same calendar year. / PH Hours to Give / PH Hours Available / PH Balance After DonationALL LEAVE THAT IS GIVEN WILL BE DEDUCTED FROM THE APPROPRIATE LEAVE BALANCE(S) Total hours may not exceed 80 for a full time employee – prorated for part time employees / Total Hours Given
Section II – Department
If you approve the leave donation, please verify leave hours and remaining balances, complete this section and the “Leave Recorder” portions of Section I of this form, and send all parts to your HR Operations Office. Prior approval by the organization budget authority is required where a charge transfer is involved.Budget Name: / Budget Number(s) to be Charged: / UW Box Number:
Name of Department Contact Responsible for Maintaining Leave Record: / Contact Phone: / Contact Email:
The donating employee meets the eligibility requirements stated above in Section I. I approve this request to donate leave hours and verify that sufficient funds are available to cover the charge transfers.
Name of Administrator or Manager (print or type): / Signature: ______/ Date:
Name of Budget Authority (print or type): / Signature: ______/ Date:
Section III –HR Operations Office
The cash value of these hours will be credited to the shared leave account of the designated employee. As applicable, this amount will be charged to your department budget as it is used by the designated employee. / ______Annual Leave Hours / The above-named employee is eligible to donate the following leave effective:______
Month/Date/Year
______Sick Leave Hours
______Personal Holiday Hours
HR Office Approval Signature:______/ Date: / Phone:
(HR Operations: Upon Completion, return two copies to Department [Department copy and Donor copy]. Make copies for employee file and Shared Leave File)
HR Operations Offices
Campus HR OperationsRoosevelt Commons West
Box 354963
4300 Roosevelt Way NE
Seattle, WA 98195-4963
Phone: 206-543-2354
Fax: 206-685-0636 / UW Medical Center
UWMC BB150
Box 356054
1959 NE Pacific St
Seattle, WA 98195-6054
Phone: 206-598-6116
Fax: 206-598-4610 / Harborview Medical Center
Pat Steel Building
Box 359715
325 Ninth Ave
Seattle, WA 98195-9715
Phone: 206-744-9220
Fax: 206-744-9955
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