PERSONNEL                                                                                                             03. 1232 AP.2 1
RequestÊto Donate Sick Leave
MORGAN COUNTY BOARD OF EDUCATION
"155 U n iversity Drive, West Liberty, KY 41472"
Name                                                                            School/Work Site:
Social Security N umber   .                         .I Number of Sick Leave Days I wi sh to Donate:
Note:  The number of  days donated may not reduce the employee's accumulated sick leave balance to less thanfrfi een (!5) days.
District Employee to whom I Wish to Donate Days:
"Note: Certified  employees may only donate days to other certified employees. Likewise., classified employees only to other classified employees."
Employee's Signature                                                                Date
THIS SECTION TO BE COMPLETED BY CENTRA L OFFICE DESIGNEE
The employee to whom sick leave days are to be donated:
Is eligi ble ¥         Is not el igi ble ¥
to receive the days based on the following criteria.
Check each requirem ent below that i s met:
¥  The  donation  wi ll  i nvolve  a  transfer  of  days  from  certified  em ployee  to  certified employee or from classified employee to classi fied em ployee.
¥ The donating employee's sick  leave balance wi ll  not  fa ll  below fifteen ( 15) days.
"¥ The receiv i ng em ployee or a mem ber of h is/her immed iate fam i ly su ffers from a medica lly certified  illness, injury,  impairmen t, or physical or mental cond ition  that has caused or is I ikely to cause the employee to be absent for at least ten ( I 0) days."
¥ The receiving em ployee's need  for the absence and  use of sick  leave are certified  by a l icensed physician (as attached).
"¥ The receiving employee or a mem ber of his/her im mediate family suffers from a medically certified illness, injury, impa irment, or physical or menta l cond i tion that has caused or is likely to cause the employee to be absent for at least ten ( 10) days."
¥ The receiving employee has exhausted h is/her accumu lated sick leave and any other pa id leave granted  by the Board.
¥ The receiving employee has compl ied with the District's pol icies govern ing the use of sick leave.
Signature of Superintendent/designee                                       Date
Review/Revised :3/17/201 1
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