Leave transfer program recipient application for personnel use only




Yüklə 40.09 Kb.
tarix29.02.2016
ölçüsü40.09 Kb.

This form is available electronically.

LEAVE TRANSFER PROGRAM - RECIPIENT APPLICATION

FOR PERSONNEL USE ONLY:

CASE NUMBER

     

INSTRUCTIONS: Use this form to apply to be a leave recipient under P.L. 100-566. Attach to this form a brief description of the nature and severity of the medical emergency and appropriate documentation of the medical emergency: a physician's certificate, the medical prognosis and anticipated duration of the condition. After completing this form, forward through your supervisor to the office in your agency designated to approve leave recipients. Approval as a leave recipient does not guarantee that leave will be donated. Donor employees will designate the recipient of their leave.

PART I - APPLICATION AND CERTIFICATION (To be completed by the applicant or another employee on his or her behalf)

1. NAME OF RECIPIENT (Last, First, Middle Initial)

2. POSITION TITLE

3. SOCIAL SECURITY NUMBER

     

     

     

4. SERIES, GRADE OR PAY LEVEL

5. DUTY STATION

6. ORGANIZATIONAL TITLE (Agency, Division, Branch Section)

     

     

     

7. OFFICE ADDRESS




8. OFFICE TELEPHONE NO.

9. HOME TELEPHONE NO.

     

     

     

10. NAME OF TIMEKEEPER

11. TELEPHONE NO. OF TIMEKEEPER

12. OFFICE ADDRESS OF TIMEKEEPER

     

     

    

13. T&A CONTACT POINT NO.

14. ANTICIPATED OR ACTUAL

DURATION OF MEDICAL

EMERGENCY (if known)


15. DATES LEAVE

EXHAUSTED



16. AMOUNT OF DONATED LEAVE

REQUESTED (hours, days or



months)

     

Beginning Date:

Ending Date:

Annual:

Sick (if applicable):

   

     

     

    

    

17. PLEASE INDICATE HOW YOU PREFER THE ANNUAL LEAVE DONATED TO BE APPLIED BY NUMBERING THE FOLLOWING IN ORDER OF YOUR PREFERENCE. (Donated annual leave may be applied to retroactively replace leave without pay and/or advanced sick or annual leave in connection with this medical emergency.)


PLEASE INDICATE PAY PERIOD DONATED ANNUAL LEAVE MAY BE RETROACTIVELY APPLIED

   

For current use

   

against advanced

annual leave



   

against advanced

sick leave



   

against LWOP

   




18. I agree to have my (please specify)



case number only



case number, and circumstances only



name, case number and circumstances

published for the purpose of receiving donations. If I agree to have my circumstances published, the following 5 lines or less describing my medical emergency will be published exactly as I write it and will be published exactly as I write made available to employees of my agency who which to make donations to me.

     

CERTIFICATION (If certifying on behalf of another employee, modify as appropriate.)
I certify that (1) I have been affected by the medical emergency described in the attachment since the date indicated above, (2) I have or will have exhausted all annual leave and any available sick leave that could otherwise be used as of date indicated above, and (3) expect to be absent from duty without paid leave at least 80 hours because of this medical emergency. I further certify that I am not receiving unemployment benefits or workers' compensation benefits in connection with this medical emergency for which I am requesting transferred annual leave.

SIGNATURE OF RECIPIENT OR HIS OR HER DESIGNEE (please specify):

DATE



Recipient




     



Designee




CONCURRENCE: SIGNATURE OF SUPERVISOR

TITLE

OFFICE TELEPHONE NO.

DATE



Yes




     

     

     



No




PART II - AGENCY REVIEW AND APPROVAL

1. CURRENT ANNUAL

LEAVE BALANCE



(in hours)

2. CURRENT SICK

LEAVE BALANCE



(in hours)

3. LWOP HOURS USED

IN CONJUNCTION

WITH THIS

EMERGENCY



4. ADVANCED SICK

LEAVE HOURS TO

DATE


5. ADVANCED ANNUAL

LEAVE HOURS TO DATE



6. ANNUAL LEAVE CATEGORY

PER PAY PERIOD



    

    

    

    

    

 

APPLICATION APPROVED:



Yes

(If Yes, transferred leave may be credited to the recipient's account effective Pay Period Number):

  






No

(state reason for disapproval):

     

SIGNATURE OF APPROVING OR DISAPPROVING OFFICIAL

TITLE

OFFICE TELEPHONE NO.

DATE




     

     

     

PRIVACY ACT STATEMENT

§ U.S.C. 6311 authorizes collection of this information. Your social security number may be disclosed to leave donors for the purpose of positively identifying leave recipients so that donated leave can be credited to the proper account.




AD-1046

REV(4-89)


Verilənlər bazası müəlliflik hüququ ilə müdafiə olunur ©azrefs.org 2016
rəhbərliyinə müraciət

    Ana səhifə