University Policy 6.9, Time Away from Work (Excluding Academic and Bargaining Unit Staff) allows regular staff members who have completed one year of service to voluntarily donate leave to other regular staff members within a college/unit, when a health-related catastrophic event has been experienced. The conditions under which such donations may be made are outlined in the University Policy 6.9, Time Away from Work (Excluding Academic and Bargaining Unit Staff). (http://www.policy.cornell.edu/CM_Images/Uploads/POL/vol6_9.html).

This leave donation form will be retained in the college/unit for recordkeeping purposes, along with the name and leave balance records of the recipient. The college/unit representative administering the leave donation program will ensure that the information on this form gets communicated to the central Payroll Office in a timely fashion. A copy of this form may be provided to the donor but should not be provided to the recipient out of respect for the confidential nature of the leave donation program.

DONOR INFORMATION:

I hereby authorize the Payroll Office to deduct up to xday(s) from my vacation balance and/or up to xday(s) from my sick leave balance to be voluntarily donated to a staff member who currently qualifies as a recipient under the Catastrophic Leave Donation policy. I understand that donations must be made in full-day increments and that one full day equals one-fifth (1/5) of my total standard weekly hours. I certify that: :

• the days donated are not days I would otherwise forfeit or not be entitled to use.
• after making such donation, I will still have at least a combined total of 15 days of sick leave and vacation.
• I will respect the confidential nature of this donation.

OHR 7/21/04