CONFIDENTIAL		Abraham Baldwin Agricultural College
		Shared Leave Request
Employee name:		Last				First
ABAC ID#				Complete campus mailing address
Email					Work phone				Home phone
	Number of hours of shared leave this request.				If you receive leave donations, HR will notify your department about the adjustment to your leave balance.  Please provide the name and campus mailing address of the person responsible for your payroll.
	Number of previous requests for shared leave this calendar year.
					Name
I hereby request permission from the ABAC Shared Leave Committee, to solicit leave donations from other ABAC employees to be added to my sick leave account.  I request that I be permitted to receive the number of donated leave hours requested above.
					Complete campus mailing address
I certify all the following are true:
▀	I am a benefit-eligible employee of ABAC and have completed my probationary period.						Full time		Part time
▀	I am, or will soon be, experiencing a life-threatening or emergency medical condition as certified by my physician on the attached Physician's Certification of Emergency Medical Condition Form.
▀	I anticipate this condition will cause me to be absent from work either continuously or intermittently between (date) ___________ and (date) ___________.
▀	I have either exhausted all my sick and annual leave or I will exhaust all my sick and annual leave before this medical condition is resolved.
▀	After my sick and annual leave are exhausted, I will not receive any other monetary benefit based on my employment with ABAC, e.g., I will not receive, workers' compensation benefits, or disability benefits during the time for which I am requesting shared leave.
▀	I understand if my request for permission to solicit donated leave is approved, it will be my responsibility to contact potential donors and request they submit an ABAC Shared Leave Donation Form to Human Resources in order to donate leave to my account.  I further understand I may not use ABAC e-mail to solicit donations, since shared medical information is a violation of HIPAA privacy laws.
▀	I understand I will not be allowed to receive leave donations from my direct or indirect subordinates or supervisor(s).
▀	I understand any donated leave I do not use during this medical emergency will be returned to the donor(s).
▀	I understand any medical information forwarded to the Shared Leave Committee will remain confidential.
									Send this completed form in a "confidential" envelope to:
Employee Signature				Date					Office of Human Resources
									Abraham Baldwin Agricultural College
(Or the printed name and signature of the person having documented power of attorney for the named employee.  Attach documentation of power of attorney.)									ABAC 33,  2802 Moore Highway
									Tifton, GA  31793-2601