_______________________________, an employee in the Department of _________________________ has requested

 vacation/compensatory leave donations under our Catastrophic Illness Program.  _______________________ meets the conditions of our

 Catastrophic Illness Program.  If you wish to donate vacation or compensatory leave, please complete the form below and return to your Agency

 Personnel Contact at:   ________________________________________________________.

Catastrophic Illness Donation Form

To be eligible to donate vacation/compensatory leave: 

1.  Only four (4) hour increments of vacation/compensatory leave may be donated. 

2.  Must not have solicited nor accepted anything of value in exchange for the donation. 

3.  Must have remaining to his/her credit at least 40 hours of accrued vacation leave, after donating vacation leave. 

Name of employee you are contributing to ______________________________________ 

Number of whole hours of vacation/compensatory you are donating _______________________ 

I understand my vacation/compensatory leave balance will be decreased by the hours I am donating and that my vacation/compensatory leave shall be irrevocably credited to the recipient’s sick leave account. 

Your Signature _____________________________________________________ 

Your   NIS  employee ID number  ________________________________________       

Witness' Signature __________________________________________________ 

Date _____________________________________________________________  

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