Consent to receive donations of vacation or paid time off

Giving consent does not guarantee donations

Employee information
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Leave information
Leave for birth/adoption?

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mm/dd/yyyy
Leave for death of family member?

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mm/dd/yyyy
Leave for your own or a family member's illness or injury?

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mm/dd/yyyy

Type N/A if this does not apply.

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mm/dd/yyyy

Type N/A if this does not apply.

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Have you submitted a leave of absence form to the Leave and Accommodation Management (LAM) Office?

The leave of absence request form can be found here.

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Supervisor information
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Voluntary request for your name to be posted on an internal donation page

The employee request for vacation/PTO donation page is an employee driven page and names are posted by employee request only. Posting of names on this page is not intended in any way to confirm the legitimacy of a request or show favoritism of one employee over another. Your name does not need to be posted to receive donations.

Visit the page (must have network access).

Vacation/PTO donation posting page conditions:

  • Posting will be valid for 60 days
  • The posting does not guarantee donations
  • To extend the posting beyond 60 days, submit a new request
  • Names may be viewed by any employee of Hennepin County
  • To remove your name before 60 days is up, request it in writing to an HR leave specialist at hr.lam.office@hennepin.us and it will be removed within one working day from the date the request is received

I agree to the terms
Other
Signature

Having read and understood the description of the Hennepin County vacation/PTO donation program, I agree to accept the value of vacation/PTO hours donated in my name. I understand that this consent is valid until I cancel it in writing or no longer qualify to participate in the program.

Having read and understood the description of the Hennepin County vacation/PTO donation program, I agree to accept the value of vacation/PTO hours donated in my name. I understand that this consent is valid until I cancel it in writing or no longer qualify to participate in the program.
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I accept these terms.
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mm/dd/yyyy
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