UNIVERSITY OF WISCONSIN SYSTEM
INTENT TO DONATE BONE MARROW OR A HUMAN ORGAN

1999 Wisconsin ACT 125
Wis. Stats. 230.35 (2d)

Instructions for Processing Form

Donor Name (Last, First, Middle Int.) Social Security Number

University Institution

UW:
Reason for Leave Request: Bone Marrow Donation (May receive up to 5 work days in pay status)
Human Organ Donation (May receive up to 30 work days in pay status)
Number the leave categories in the priority to be charged if applicable:
_______ Annual Leave _______ Sick Leave
_______ Sabbatical _______ Leave without Pay
_______ Personal Holiday Leave


I understand this leave meets the requirements and conditions of the Wisconsin (WFMLA) and/or Federal Family and Medical Leave Act (FMLA). If needed, the appointing authority will charge the additional leave to the categories indicated above and file timesheets accordingly. I understand that I may contact my Supervisor or Director to change these leave elections if I so choose.
Date (Mo/Day/Yr)

Employee Signature


Physician's Certification
I certify that the individual named above will be a donor as indicated below.
Employee will be:
Bone Marrow Donor Human Organ Donor
Date (Mo/Day/Yr)

Physician's Signature:

Provider/Clinic Name

Address Street

City
State
Zipcode

Supervisor/Director and Human Resource Representatives Notification
Date (Mo/Day/Yr)

Supervisor/Director Signature

Family Medical Leave Act (FLMA)

This leave will be counted towards your annual FMLA allotment.
Yes No Check one (If Yes, complete required form)
Date (Mo/Day/Yr)

Human Resource Representative Signature:

NOTE: THIS DOCUMENT WAS DEVELOPED TO MEET THE MINIMUM REQUIREMENTS OF WISCONSIN ACT 125.

Copies of all documentation shall be retained in the Human Resources/Personnel Office

Copy 1 Campus Human Resource Office
Copy 2 Employee

UW1259 10/00

File last updated: July 23, 2010
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