"Employee-To-Employee Leave Donation Request Packet" - Maryland

Employee-To-Employee Leave Donation Request Packet is a legal document that was released by the Maryland Department of Budget and Management - a government authority operating within Maryland.

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STATE EMPLOYEE-TO-EMPLOYEE LEAVE DONATION PROGRAM
INSTRUCTIONS FOR SUBMITTING AN
EMPLOYEE-TO-EMPLOYEE DONATION LEAVE REQUEST
This packet contains information and all forms necessary to request leave from the
Employee-to-Employee Leave Donation Program:
1. Fact Sheet for the Employee-to-Employee Leave Donation Program– Contains
general information about donating and receiving leave from the Employee-to-
Employee Leave Donation Program.
2. Employee-to-Employee Leave Donation Program - Request Form (MS405) –
• Part I – To be completed by employee donating leave and their Agency
Appointing Authority
• Part II - To be completed by employee receiving leave and their Agency
Appointing Authority
3. Employee-to-Employee Leave Donation Program - Medical Certification Form
(MS402-EE) – Please have your treating physician(s) complete; submit the medical
form with Form MS 405 and the HIPAA form to your HR Office.
4. Authorization Form for Review of Records & Information (HIPAA Form) – Please
sign, date and submit, with the MS 402 and MS 405, to your HR Office.
5. Employee-to-Employee Leave Donation Program – Medical Documentation –
Provides examples of medical records that should be provided by your treating
physician(s) to support only the dates for which you are requesting leave. Have
physician provide you with as much additional medical documents as possible for the
period of leave that is being requested.
MEDICAL RECORDS*
Medical records that address and support your work absence are the best documentation
to provide for favorable consideration of your request. For example, if you need leave to
cover your absence from January 1 to January 15, ask your treating physician(s) to
submit actual medical records that address the period from January 1 to January 15.
*If your request is for surgery, proof of surgery must be provided upon your initial
request.
*If your request is for birth of a child, proof and type of birth (normal or C-section) is
required.
STATE EMPLOYEE-TO-EMPLOYEE LEAVE DONATION PROGRAM
INSTRUCTIONS FOR SUBMITTING AN
EMPLOYEE-TO-EMPLOYEE DONATION LEAVE REQUEST
This packet contains information and all forms necessary to request leave from the
Employee-to-Employee Leave Donation Program:
1. Fact Sheet for the Employee-to-Employee Leave Donation Program– Contains
general information about donating and receiving leave from the Employee-to-
Employee Leave Donation Program.
2. Employee-to-Employee Leave Donation Program - Request Form (MS405) –
• Part I – To be completed by employee donating leave and their Agency
Appointing Authority
• Part II - To be completed by employee receiving leave and their Agency
Appointing Authority
3. Employee-to-Employee Leave Donation Program - Medical Certification Form
(MS402-EE) – Please have your treating physician(s) complete; submit the medical
form with Form MS 405 and the HIPAA form to your HR Office.
4. Authorization Form for Review of Records & Information (HIPAA Form) – Please
sign, date and submit, with the MS 402 and MS 405, to your HR Office.
5. Employee-to-Employee Leave Donation Program – Medical Documentation –
Provides examples of medical records that should be provided by your treating
physician(s) to support only the dates for which you are requesting leave. Have
physician provide you with as much additional medical documents as possible for the
period of leave that is being requested.
MEDICAL RECORDS*
Medical records that address and support your work absence are the best documentation
to provide for favorable consideration of your request. For example, if you need leave to
cover your absence from January 1 to January 15, ask your treating physician(s) to
submit actual medical records that address the period from January 1 to January 15.
*If your request is for surgery, proof of surgery must be provided upon your initial
request.
*If your request is for birth of a child, proof and type of birth (normal or C-section) is
required.
STATE EMPLOYEE-TO-EMPLOYEE LEAVE DONATION PROGRAM
FACT SHEET
FOR EMPLOYEES DONATING LEAVE TO OTHER EMPLOYEES:
Employees may voluntarily donate unused annual, sick or personal leave to another employee.
An employee who donates sick leave to another employee must maintain a sick leave balance of at
least 240 hours after the donation is deducted.
An employee who donates leave shall designate the recipient of the leave.
If an employee who receives leave does not use all of the donated leave, the remaining hours of leave
shall be restored to the employee(s) who made the donation, by their Appointing Authority (new).
To donate leave to another employee, please complete Part I of the State Employees’ Leave Donation
Form (MS405) and submit the form to your HR Office. You should also provide a copy of the form to the
employee to whom you are making the donation. The form is available from your HR Office or on the
Department of Budget and Management website at www.dbm.maryland.gov.
FOR EMPLOYEES RECEIVING LEAVE FROM OTHER EMPLOYEES:
To qualify for leave from the Employee-to-Employee Leave Donation Program, an employee must:
• have exhausted all available annual, personal, sick and compensatory leave because of:
1) a personal serious and prolonged medical condition that exists at the time the leave is donated; or
2) a catastrophic illness or injury of a member of the employee’s immediate family for whom the
employee is needed to provide direct care. Catastrophic illness or injury is defined as a condition
that is incapacitating or life threatening as certified by a health care provider. An employee may
use leave from another employee to care for a family member only after obtaining approval from the
employee’s appointing authority. The appointing authority’s approval is discretionary and denial
may be based on any reason which is consistently applied and is not illegal or unconstitutional.
• qualify for the use of sick leave under the requirements of the employee’s personnel system;
• must provide sufficient medical documentation to substantiate absence for the time period covered by
the Employee-to-Employee Leave request;
• in all likelihood be able to return to work;
• have received less than 2,080 hours of leave from the Leave Bank and the Employee-to-Employee
Leave Donation Programs; and
• not have used more than 16 continuous months of leave from the Leave Bank, Employee-to-Employee
Leave Donation Program and all other forms of paid leave.
To request leave from another employee, please complete Part II of the State Employees’ Leave Donation
Form (MS405) and submit the form to your HR Office. You must also have the treatment provider complete
an Employee-to-Employee Leave Donation Program Medical Certification Form (MS402-EE) and provide
medical records that address the absence for which Employee-to-Employee Leave is requested. The forms
are available from your HR Office or on the Department of Budget and Management website at
www.dbm.maryland.gov. Please submit completed forms and medical documentation to your HR Office.
(Rev. 4/2018)
EMPLOYEE-TO-EMPLOYEE LEAVE DONATION PROGRAM - REQUEST FORM
PART I - TO BE COMPLETED BY DONATING EMPLOYEE
(Please TYPE or PRINT with black or blue Ink)
Name of Employee Receiving Donations:
Receiving Employee’s Agency Name:
Name of Donating Employee*:
SS# of Donating Employee*:
* Your full Name and Social Security Number is required to help verify your identity. Failure to provide it may result in delays and/or rejection of this request.
This information is kept confidential in accordance with Federal and State laws and regulations.
Agency Name:
Agency Code:
TYPE OF LEAVE DONATED:
TOTAL HOURS DONATED:
[
] SICK**
[
] ANNUAL
[
] PERSONAL
I understand that if the employee to whom I am donating leave does not use the leave for any reason, the unused
donated leave shall be returned to my leave balances by my Appointing Authority.
Signature:
Date:
** If you are donating sick leave, you must maintain a balance of at least 240 hours of sick leave after
the donation is deducted.
CERTIFICATION OF LEAVE FOR DONATING EMPLOYEE –
TO BE COMPLETED BY APPOINTING AUTHORITY/DESIGNEE
ANNUAL/PERSONAL LEAVE CERTIFICATION: I have reviewed this employee’s leave balances and affirm
that s/he has sufficient annual/personal leave to make this donation.
SICK LEAVE CERTIFICATION: I have reviewed this employee’s sick leave balance. I affirm that s/he will
have a sick leave balance of at least 240 hours after this donation. As the Appointing Authority/Designee for
the employee making the above leave donation, I certify this donation is in compliance with COMAR
17.04.11.22 C (3).
_______________________________________________
_________________________
APPOINTING AUTHORITY/DESIGNEE
DATE
(Per COMAR 17.04.11.22 C (11) The appointing authority of an employee who donates leave shall adjust the
donating employee’s leave balance before forwarding a copy of the MS 405 form to the receiving employee’s
appointing authority. If the receiving employee is denied the use of donated leave, the receiving employee’s
appointing authority shall notify the donating employee’s appointing authority within 7 days of the denial, and the
donating employee’s appointing authority shall restore the leave balance of the donating employee within 14 days
of notification from the receiving employee’s appointing authority.)
MS 405
Page 1 of 2
(Rev.4/2018)
EMPLOYEE-TO-EMPLOYEE LEAVE DONATION PROGRAM - REQUEST FORM
PART II - TO BE COMPLETED BY EMPLOYEE RECEIVING LEAVE DONATIONS
(
Please TYPE or PRINT with Black or Blue ink)
Name*:
SS#*:
* Your full Name and Social Security Number is required to help verify your identity and process your Request. Failure to provide it may result in delays
and/or rejection of your request. This information is kept confidential in accordance with Federal and State laws and regulations.
Job Title and brief description of duties:
Home Address:
City/State/Zip:
Agency Name:
Request Type:
New
Extension
Reason for Request:
An illness or disability of the employee due to a serious and prolonged medical condition that existed at the time
or
the leave was donated;
A catastrophic illness or injury of a member of the employee's immediate family for whom the employee is
needed to provide direct care**.
**For family member please provide - Name:
Relationship:
**Describe care to be provided:
Signature:
Date:
TO BE COMPLETED BY AGENCY LEAVE BANK/DONATION COORDINATOR
Leave Bank/Donation Coordinator:
Email:
Phone #:
Fax #:
Employee Hire Date:
Last Day Employee Worked: ___________
Dates to Cover: From: ___________ Through: ___________
Donations Received: _________ Hrs
Hours Needed: __________ Hrs
Is employee on FMLA leave? No
Yes
If Yes, provide end date of current FMLA:
Has the employee been seen by the State Medical Director? No
Yes
If Yes, provide copy of SMD Report
Leave Coordinator’s Signature:
Date:
COMPLETED BY APPOINTING AUTHORITY/DESIGNEE
As the Appointing Authority/Designee for the employee receiving the leave donation, I certify that this employee has
exhausted all forms of annual, sick, personal and compensatory time because of a serious and prolonged medical condition.
Approval will not cause the employee to exceed 2,080 hours of leave from the Leave Bank and/or Employee-to-Employee Leave
Donation Programs during his/her entire State employment. Approval will not cause the employee to exceed 16 months of
continuous leave, when combined with all other forms of paid leave. As the appointing authority or designee for this employee, I
have reviewed the employee’s records and I certify that this request meets all of the criteria specified in this Section.
______________________________________________________________
______________________________________
Signature of Appointing Authority or Designee
Date
Page 2 of 2
MS 405
(Rev. 4/2018)
STATE EMPLOYEE-TO-EMPLOYEE LEAVE DONATION PROGRAM
MEDICAL CERTIFICATION FORM
TO BE COMPLETED BY TREATING PHYSICIAN
EMPLOYEE’S NAME:
PATIENT’S NAME
:
(if not employee)
DIAGNOSIS(ES):
ICD 10 CODE(S):
SUMMARY OF TREATMENT(S) & PROCEDURE(S):
START DATE OF CURRENT INCAPACITY:
SURGERY DATE (IF APPLICABLE):
HOSPITALIZATION DATE(S) (IF APPLICABLE): FROM:
TO:
CAN EMPLOYEE WORK IN A MODIFIED CAPACITY? YES:
NO:
IF YES, PROVIDE RESTRICTIONS FOR MODIFIED DUTY:
__________________________________________________________________________
PROVIDE DATE EMPLOYEE IS LIKELY TO RETURN TO:
MODIFIED DUTY: __________________________
FULL DUTY: _______________________
____________________________________________
____________________________________
PHYSICIAN’S NAME (PRINTED)
PHYSICIAN’S PHONE NUMBER
____________________________________________
____________________________________
PHYSICIAN’S SIGNATURE
DATE FORM COMPLETED
(PLEASE ATTACH MEDICAL VERIFICATION OF SURGERY OR BIRTH;
TYPE OF BIRTH IS REQUIRED)
Failure to provide sufficient medical documentation may delay the processing of this request. This
information shall be treated as a confidential medical record; it shall not be placed in the employee’s
personnel file. Only those individuals with a need to know this information will be given access to it. An
employee who fails to appropriately safeguard the confidentiality of this information will be subject to
disciplinary action, including termination from State Service.
MS 402-EE
(Rev. 4/2018)
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