Sick Leave Form – Fill Out and Use This PDF

The University of Toledo

Professional Staff Association (PSA)

SICK LEAVE DONATION FORM

(Please Print)

Name of Donor Employee: (Last, First, Middle)

Rocket Number:

Title of Donor Employee:

Department / Location / Mail Stop:

Office Telephone:

Amount to donate (please check one):

Part Time Employee donate 8 hours (1 day)

one-time donation to sick leave bank to become a member

Full Time Employee donate 16 hours (2 days)

one-time donation to sick leave bank to become a member

I hereby authorize the Payroll/Human Resources Department to deduct from my sick leave balance the number of hours indicated above to be used as sick leave by the Professional Staff Association Sick Leave Bank.

Please sign and return Donation form to Deborah J. Sobczak, PSA SLB Committee Chair, MS 608, if you wish to be a member of the Sick Leave Bank. Donation forms must be received by March 31, 2013.

Signature: __________________________________________ Date: ___________________

For Office Use Only:

Date Processed: _____________ Initials: ____________

Professional Staff Association

Sick Leave Bank Open Enrollment

Employees who have not already enrolled in the PSA Sick Leave Bank have the opportunity to do so from March 1 through March 31, 2013.

What is the Sick Leave Bank? The Sick Leave Bank is excess sick time hours contributed by PSA members to be used by PSA members who have had a personal catastrophic illness or injury and have exhausted their own vacation and sick time.

Who is eligible to join the SLB? Any PSA or classified-exempt employee (on any UT campus) who has a minimum of 48 hours of personal sick time.

How do I join? Complete and return the SLB Donation form to Deborah J. Sobczak, MS 608, no later than 3/31/2013.

Do I have to join? No, it is completely voluntary.

Do I need to Re-Enroll Each Year? No, your one-time contribution makes you a member as long as you are employed at UT.

Can I cancel my membership in the SLB? Yes. Contact the Chair of the SLB committee.

How do I apply to use hours? The Application Form is available online at the HR Web site.

Questions? Please visit our PSA Web site www.utoledo.edu/org/psa/ for entire policy guidelines or contact the Sick Leave Bank Chair, Deborah J. Sobczak at 419-530-2010.