UAMS CATASTROPHIC LEAVE BANK PROGRAM

DONOR FORM

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INSTRUCTIONS: Complete this form to donate accrued Annual or Sick Leave to the UAMS Catastrophic Leave Bank. An employee may not reduce accrued Annual or Sick Leave to less than a combined total of eighty (80) hours (except on termination). Donation of accrued leave may be in hourly increments of no less than one (1) hour.

Part 1 – Completed by Donor

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Name of Donor (Last, First, MI) Social Security Number Department

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Number of Annual Leave Hours Donated Number of Sick Leave Hours Donated

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Total Hours Donated

Certification of Voluntary Donations:

I certify that I am making this donation entirely of my own free will and not through any attempts to intimidate, threaten or coerce me to donate my Annual or Sick Leave. I understand that I have no right under any circumstances to have any of the donated Leave restored to my accrued Annual or Sick Leave totals. Further, I certify that I am a regular/full time employee of UAMS compensated on a full-time basis. I further certify that this leave donation will not reduce my combined Annual and Sick Leave balance to less than eighty (80) hours (except on termination).

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Signature of Donor Date

Part II – Completed by Donor’s Timekeeper

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Annual Leave Hours Balance After Donation Sick Leave Hours Balance After Donation

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Hourly Rate of Pay

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Department Name Timekeeper’s Signature Phone Number Date

Part III – Completed by UAMS Office of Human Resources

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Employee Status Total Leave Hours Donated X Hourly Rate of pay = Value of Donation

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Date Recorded in Leave Bank Records Signature of Recorder

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Date Received by Payroll Signature of Payroll Representative