COVID-19 Emergency Leave Donation Request Form

Berkeley Lab has established a temporary COVID-19 Emergency Leave Donation Program to enable Lab employees to assist fellow colleagues who are in need of additional paid leave for absences related to COVID-19 circumstances. This program is in accordance with The Internal Revenue Service (IRS) guidance under Notice 2006-59. Important Information: 1) This program will remain in effect until the President of the United States declares that COVID-19 is no longer a major disaster 2) Berkeley Lab employees are able to donate accrued vacation hours to a leave sharing bank to be distributed among eligible Berkeley Lab employees who have insufficient leave balances to cover their absence during a pay period 3) Sick leave cannot be donated 4) Personal Time Off (PTO) cannot be donated 6) Donations are not made to a specific individual 5) The identity of donors and recipients will be kept confidential to those administering this program Point of Contact: Integrated Disability & Absence Management Services Team Email: DisabilityManagement@lbl.gov

LBNL ID*

Name (First and Last)*

(First and Last Name)

Division*

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Preferred Email Address*

Preferred Phone Number*

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Alternate Phone Number

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Do you wish to donate your vacation leave or receive leave donations?*

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Recipient's Covid-19 Circumstance?*

Please provide a brief explanation of the circumstances warranting additional leave for COVID-19 related absences. Please do not provide any medical information or diagnosis.

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How many hours do you have in your vacation leave balance?*

Enter numerical value only.

How many hours do you have in your sick leave balance?*

Enter numerical value only.

How many hours of sick leave are you requesting for the duration of your COVID-19 related absence?*

Note: Priority of leave donations are granted based on what is needed for coverage in the current pay period.

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Do you get paid biweekly (every 2 weeks) or monthly?*

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Do you work a typical Monday through Friday schedule?*

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Recipient Disclaimer*

By submitting this form, I agree to all of the following: 1) I currently have low or exhausted sick and vacation leave balances and; 2) I authorize the transfer of leave donations into my sick leave balance per pay period and; 3) I understand that the Integrated Disability & Absence Management team will make a reasonable determination, based on the need, as to how much sick leave will be credited to me and; 4) I will not receive Unemployment Insurance benefits from the CA Employment Development Department (EDD) during any paid leave of absences Note: Any unused donated leave may be returned to the donor once the COVID-19 pandemic is no longer declared a major disaster. If you have any questions, please contact the Integrated Disability & Absence Management Services Team via email at disabilitymanagement@lbl.gov.

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How many hours of vacation leave are you donating?*

Minimum donation amount is eight (8) hours. Donations above this amount must be in four (4) hour increments. You are encouraged to not to deplete your vacation balance below 40 hours.

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Donor Disclaimer*

By submitting this form, I agree to all of the following: 1) I authorize the transfer of my vacation leave in the amount that I indicated on this form to Berkeley Lab's Emergency Leave Donation Bank and; 2) I understand that leave donations are irrevocable once they are applied to Berkeley Lab's Emergency Leave Donation Bank and; 3) I am donating my vacation leave voluntarily without coercion or intimidation, and without expectation of any benefit in exchange for this donation Note: A portion of any unused donated vacation leave may be returned to you once the COVID-19 pandemic is no longer declared a major disaster. If you have any questions, please contact the Integrated Disability & Absence Management Services Team via email at disabilitymanagement@lbl.gov.

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