Duke University/Medical Center s1

Michigan Medicine-UMPNC PTO Donation Program Donor Form

PLEASE TYPE OR PRINT INFORMATION TO BE COMPLETED BY DONOR (All fields are required)

UM ID #: Dept./Unit Name:

Last Name: First Name: M.I.:

Cell/Home Phone: Work Phone: E-mail Address:

My signature on this document certifies I understand that:  It is my responsibility to read the provisions of the UMPNC PTO Donation Program  Donations may NOT be rescinded in part or whole for any reason once submitted  Although a preferred recipient may be designated, donated hours will be added to a pool used by approved recipients  I may NOT donate hours if I am funded by a Sponsored Research Project account  I must have 80 (pro-rated by FTE), hours of PTO left over after donating hours  Hours must be donated in 2 hour blocks NUMBER OF PTO HOURS TO BE DONATED (must be in two-hour increments)

PREFFERED RECIPIENT (if Last Name: First Name: applicable)

Department Name: Supervisor Name:

Donor Date: Signature:

TO BE COMPLETED BY DONOR SUPERVISOR/MANAGER (All fields are required) Supervisor/Manager First Name: Last Name: E-Mail Address: Work Phone:

Donor’s Department ID: By signing this form, I attest the donor meets the criteria to donate PTO in accordance with the UMPNC PTO Donation Program MOU Paragraph 728. Supervisor Date: Signature: HEALTH SYSTEM PAYROLL OFFICE USE ONLY Date Received: Reviewed by: Work Phone : Name: E-Mail Address: I certify the request meets eligibility requirements of the UMPNC PTO Donation Program: Yes No

Comments: Health System Payroll Representative Signature: Date:

FAX COMPLETED FORM TO: Health System Payroll Office: 734-615-5822 Att: Primary Contact: Angela Galvin: 734-763-2912 Secondary Contact: Amanda Louks: 734-615-0330 The UMPNC PTO Donation Program Committee will send notification when hours have been deducted from Donors PTO bank.

Revised: January, 2017 | Target Audience: Nursing at Michigan | Author/Contact: Mark Kempton | Last reviewed: August 2017