Doe Ohr 300 003 Form – Fill Out and Use This PDF

I. EMPLOYEE INFORMATION (Completed by employee or representative)

Name: ______________________________________________________________			Last 4 digits of SSN: __________________
Last	First	M.I.
Mailing Address: __________________________________		City: ____________________ State: ______ Zip: ___________
Tel#: _________________________	Position: __________________________ School/Office: ___________________________
School or Sub-Division Code: _ _ _	Bargaining Unit Code: _ _		FTE: _____________%

Beginning date of employment with Department of Education: _______________________

MM/DD/YYYY

II.CERTIFICATION OF ELIGIBILITY AND APPLICATION FOR APPROVAL TO RECEIVE LEAVE SHARE DONATIONS (Completed by employee or representative)

I certify and have so indicated below that I meet each of the following conditions to be an eligible "leave share recipient". (Check √ each item appropriately, provide required information, and attach materials as requested).

Yes No

1. I have exhausted or am about to exhaust all vacation leave (if applicable, sick leave and compensatory time credits.) My leave balances as of this date are as follows: Vacation: _________ Sick: __________ Comp. Time: _________

2. I have been or soon will be absent from work for at least thirty (30) consecutive calendar days within the past twelve (12) months (exclusive of any break/vacation period for ten (10)-month employees) because of the serious illness/injury certified by my physician on DOE OHR 300-003(a) (Former DOE Form(s): LS-5, LS-6).

From: _______________________ To: _______________________

MM/DD/YYYYMM/DD/YYYY

3. I am eligible for temporary disability benefits or, if eligible, have exhausted or will shortly exhaust all benefits.

4. I am not receiving worker's compensation benefits at this time. If applicable, indicate below if a workers' compensation claim has been filed for the illness/injury identified on DOE OHR 300-003(a) (Former DOE Form(s): LS-5, LS-6). (Attach copy of claim and accident report.)

Date of injury: _______________________ Date of claim: _______________________

MM/DD/YYYY

MM/DD/YYYY

5. I have no disciplinary record of sick leave abuse within the past two (2) years.

I am requesting approval to receive __________ donated leave share days as available from the shared central leave bank and donated

for my use. I understand that approval decisions regarding this request will rely heavily on the information provided in my request. Thus, any approved credits may be discontinued or rescinded based on misinformation or changed conditions as specified

in the Department of Education’s Guidelines and Procedures for the Leave Sharing Program.

*I have attached a current copy of my Form 7 (leave record).
Employee Signature: ______________________________________________________	Date:_______________________
	MM/DD/YYYY
III. PRINCIPAL/SUPERVISOR AND DISTRICT REVIEW
I verify the above employee statements to be true and correct to the best of my knowledge.
Principal/Supervisor Signature: ______________________________________________	Date:_______________________
	MM/DD/YYYY
Complex Area/
Assistant Superintendent Signature: ___________________________________________	Date:_______________________
	MM/DD/YYYY

Distribution: 1. Original - OHR, Records and Transactions Section; 2. Copy 1 - School/Office; 3. Copy 2 - Employee

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