EFFECTIVE: December 1, 2011
REFERENCE: Board Policy on Employee Benefits, BP 3-60
/ Nancy J. McCallin /
Nancy J. McCallin, Ph.D.
To establish a means to voluntarily transfer sick leave designated as leave for personal reasons to a qualifying faculty member (as defined in BP 3-10) experiencing a catastrophic medical hardship. This program provides some income protection when the faculty member would be absent from work for a prolonged period of time and has exhausted all sick leave. It is not intended to cover cases of abusive leave usage.
This transfer program is intended for faculty members with a minimum of one year of service to cover catastrophic illness or injury, such as cancer, major surgery, serious accident, heart attack, etc., that poses a threat to the faculty member’s life and requires inpatient, hospice or resident health care.
The applicant must have exhausted all sick leave (as permitted under BP 3-60) before applying for transferred leave.
Application must be made on the appropriate form provided by the Human Resources Office. The application must be approved by the requesting faculty member’s supervisor prior to submission. The college president must give final approval to the application.
Approval or disapproval will be based on the merits of each individual case and the following guidelines:
Normal pregnancy, common illness, coverage by Worker’s Compensation, or PERA disability are excluded.
Contributions must be made by faculty members at the applicant’s college from accrued sick leave designated as leave for personal reasons and is credited to the recipient on an hour-for-hour basis. A minimum donation of two hours of accrued sick leave designated as leave for personal reasons is required. (The faculty member is encouraged to keep some balance for his/her own use). The maximum donation from an employee to an individual faculty member is 8 hours.
Contributions are voluntary and confidential.
Contributions will no longer be accepted when the amount needed has been received. When more contributions are available than needed, donors will receive a proportionate refund (number of extra hours/number of donors).
Name________________________________ Employee S# ________________________________________
Home Telephone_______________________________ Work Unit __________________________________
Job Title _____________________________________ Full Time ______ Part Time _____ % Appt______
I hereby certify that I understand, agree to, and meet the requirements and conditions of the leave transfer program. I also hereby authorize the College President or his/her designee to obtain any necessary information concerning this application. I understand that denial of this application is not subject to grievance or appeal.
Signature of Employee_____________________________________ Date___________________________
Date Benefit Eligible Employment began ______________________ Monthly Salary _________________
Has employee requested/applied for: Worker’s Comp ____ FMLA_____ LTD_____ PERA Disability______
Is Medical Certification verifying catastrophic illness on file? Yes _____ No_____
Date illness/injury began _______________________ Anticipated duration ____________________________
Date all sick leave will be/was exhausted ________________ Number of days needed ___________________
Signature of Human Resources__________________________________ Date________________________
Authorization to request donated leave is:
Approved Denied Signature of Supervisor_____________________________ Date_________________
Approved Denied Signature of President______________________________ Date_________________
Please type or print legibly in ink.
Name______________________________ _____________________________ Employee S#______________
Full Time ___ Part Time ___ % Appt ____ Job Title_______________________________________________
Work Unit_____________________________ Work Phone _________________________________________
Number of hours donated ______________ To (Employee/Case #): _____________________________________
I understand that my contribution is voluntary and that my balance of sick leave designated as leave for personal reasons will be decreased by the amount contributed. I certify that my contribution will not result in a negative leave balance. I understand that my contribution is confidential.
For College/HR Use:
The above named employee’s leave balance has been reduced by ______________ hours of sick leave designated as leave for personal reasons.
(Authorized College/HR Signature) (Date)