This form is self explanatory as to the information requested.
Complete the boxes requesting your name, Social Security number, UW institution and department. In the section titled Reason for Leave check whichever box is appropriate, Bone Marrow Donation or Human Organ Donation. In the event your recovery time exceeds the term of leave authorized please numerically check, 1 through 5, the leave categories that you would like the extended leave charged to. Finally date and sign the document.
It is your responsibility to secure the Physician’s Certification. The physician must confirm the category of donation, bone or organ, sign and provide their practice address.
Once this information has been collected submit the form to your Supervisor/Director. You are not required, nor is it recommended, to attach or include any personal medical information pertaining to this request.
The Supervisor/Director must date, sign and indicate whether this leave will be charged towards your annual Family Medical Leave (FMLA) allotment. Approval of this leave is not optional as it is guaranteed by Wis. Stats. §230.35(2d). If this leave is to be charged to FMLA the proper forms should be completed at that time. The Supervisor/Director should then forward all documentation to their Human Resources/Personnel Office.
Human Resources/Personnel shall sign the document acknowledging receipt of all required information. Human Resources/Personnel shall copy the completed document(s) and forward them to the donor employee for their records, in an envelope stamped CONFIDENTAL.
It is the responsibility of the Human Resources/Personnel to coordinate the leave with the institution's payroll/leave office.
File last updated: March 19, 2007
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