Instructions for Form 25 "Request for Donated Leave" - Alabama

This document contains official instructions for Form 25, Request for Donated Leave - a form released and collected by the State of Alabama Personnel Department.

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STATE OF ALABAMA
PERSONNEL DEPARTMENT
REQUEST FOR DONATED LEAVE
Instructions for Form 25
A doctor’s statement giving the diagnosis and the specific nature of the situation must be
attached to this form.
There is a place at the top to check whether the form is being submitted as an initial request or a
recertification. In either case, the original must be submitted to State Personnel. If the absence
is for more than thirty days, a recertification Form 25 must be submitted, accompanied by a
statement from the physician certifying that the employee is still incapacitated with the same
illness/injury. These updates must be completed every thirty days in order for the employee to
continue to receive donated leave.
To be completed by the employee or their advocate:
Employee Name – complete name as it appears in GHRS
SSAN – full Social Security Number must be given
Department – name (not number) of the employee’s agency
Division – name or number designation of the employee’s division if applicable
Class Code – the 5 digit class code (do not enter the title)
Pay Range – pay grade assigned to the class
Additional Information:
The employee or their advocate may enter pertinent information if they so desire. In
caretaker instances, the name of the person to receive care and their relationship to the
employee should be given in this space.
Signature Block/Date:
Beneficiary Employee: The beneficiary employee must sign unless they are physically
unable to do so. If an advocate signs, they should sign their own name, their relationship
to the employee, and the reason the employee is unable to sign. (i.e. in a coma) The date
of the signature should be entered.
Authorization/Date:
Beneficiary Employee: The beneficiary employee must sign this waiver if they wish to
be listed on the State Personnel website and other publications. If they do not, the line
should remain blank.
Beneficiary Appointing Authority/Date:
The beneficiary appointing authority must sign and date the appropriate line giving
departmental permission for this employee to receive donated leave, if approved.
Approved Personnel Director/Date: If approved, the form will be signed and dated. Leave cannot
be granted before this date.
Donated Leave Approved For: The illness/injury for which donated leave has been approved will
be printed here.
STATE OF ALABAMA
PERSONNEL DEPARTMENT
REQUEST FOR DONATED LEAVE
Instructions for Form 25
A doctor’s statement giving the diagnosis and the specific nature of the situation must be
attached to this form.
There is a place at the top to check whether the form is being submitted as an initial request or a
recertification. In either case, the original must be submitted to State Personnel. If the absence
is for more than thirty days, a recertification Form 25 must be submitted, accompanied by a
statement from the physician certifying that the employee is still incapacitated with the same
illness/injury. These updates must be completed every thirty days in order for the employee to
continue to receive donated leave.
To be completed by the employee or their advocate:
Employee Name – complete name as it appears in GHRS
SSAN – full Social Security Number must be given
Department – name (not number) of the employee’s agency
Division – name or number designation of the employee’s division if applicable
Class Code – the 5 digit class code (do not enter the title)
Pay Range – pay grade assigned to the class
Additional Information:
The employee or their advocate may enter pertinent information if they so desire. In
caretaker instances, the name of the person to receive care and their relationship to the
employee should be given in this space.
Signature Block/Date:
Beneficiary Employee: The beneficiary employee must sign unless they are physically
unable to do so. If an advocate signs, they should sign their own name, their relationship
to the employee, and the reason the employee is unable to sign. (i.e. in a coma) The date
of the signature should be entered.
Authorization/Date:
Beneficiary Employee: The beneficiary employee must sign this waiver if they wish to
be listed on the State Personnel website and other publications. If they do not, the line
should remain blank.
Beneficiary Appointing Authority/Date:
The beneficiary appointing authority must sign and date the appropriate line giving
departmental permission for this employee to receive donated leave, if approved.
Approved Personnel Director/Date: If approved, the form will be signed and dated. Leave cannot
be granted before this date.
Donated Leave Approved For: The illness/injury for which donated leave has been approved will
be printed here.