The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. “Genetic information,” as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.

Employee’s Name / Program/Department/Division
Sick Leave Pool
I am donating hours of sick leave to the Sick Leave Pool. I understand that I may not request the return of my donated hours unless I am (or my immediate family member is) suffering from a catastrophic illness or injury and have exhausted my entire sick, holiday, compensatory, overtime and annual leave balances within the same fiscal year.
During the fiscal year I have donated hours of sick leave to the Sick Leave Pool. I have exhausted all sick, holiday, compensatory, overtime and annual leave balances and I request the return of my previous donation due to my (or my immediate family member’s) catastrophic illness or injury. Attached is a health care provider’s statement providing a description of the illness/injury, the prognosis of recovery and my anticipated return-to-work date.
I have exhausted all of my accrued leave time and request leave hours from the Sick Leave Pool due to my (or my immediate family member’s) catastrophic illness or injury as explained by the attached statement. Sick Leave Pool hours requested: . Attached is a health care provider’s statement providing a description of the illness/injury, the prognosis of recovery and my anticipated return-to-work date.
Sick Leave Donation
I am donating hours of sick leave to (employee’s name). I understand that I may not request the return of my donated hours.

AUTHORIZATION:

Employee: / Date:

VERIFICATION:

Personnel Administrator: / Date:

APPROVAL:

Sick Leave Pool Administrator: / Date:

Signature of Personnel Administrator and Sick Leave Pool Administrator required.

Multipurpose Sick Leave Form 1 Revised: 12/1/2015