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Donated Leave Request Form

Donated Leave Request Form

Please complete this form if you have a serious medical condition that will require an absence from work and you will have no accrued leave to cover that period of absence.   
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    Any employee of the Government of the Virgin Islands, including employees of the Legislature, the judicial branch, the University of the Virgin Islands, and all independent or semi-autonomous agencies and instrumentalities of the Government of the Virgin Islands, are eligible for participation in the donated leave program:

    Work Requirement:
    Employee must have completed at least one (1) year of continuous employment with the Government of the Virgin Islands in the 12 months immediately preceding the original application for Donated Leave.

    Leave Balance Requirement:
    The employee must have exhausted all accrued sick, annual, compensatory, and administrative leave while on an approved sick leave by the start date of the donated leave absence period.

    Leave Reason Requirement:
    Employee must be suffering from a health condition including maternity, or injury, or when the employee is the primary caregiver of a seriously ill spouse, child, parent or any individual who is the legal dependent of the employee, which is expected to require a prolonged absence from work by the employee and makes the employee unable to complete the essential functions of their job for a minimum of 40 hours.

    Medical Certification Requirement:
    The employee must submit at the time of application a medical certification that certifies the anticipated time of absence from the service of the government and the reason for the leave:
    (1) Birth of a child of the employee.
    (2) Employee’s serious health condition or injury. 
    (3) Full-time assistance and primary care for a seriously ill spouse, child, parent or other individual who is a legal dependent of the employee due to his/her serious health condition.

    False reports of medical certifications will be reported to the applicable Medical Board and will subject the employee to lifetime removal from the Donated Leave Program.

     

    APPLICATION PROCEDURE
    Perspective Recipients should, prior to completing this application, complete the following:


    1. We recommend that you meet with your Human Resources Officer regarding your need for donated leave so that they can be aware of your pending absence and assist you with completing the donated leave application.

    2. Visit your doctor to complete the Donated Leave Medical Certification Form.  The Donated Leave Medical Certification or ReCertification form must be completed no more than 30 calendar days from the date you submit your Request for Donated Leave Application. Ensure that Medical Certifications are completely filled out and every question is answered. Incomplete applications will result in immediate denial. Medical Certifications with no return date will be denied and the employee will be provided with information regarding GERS disability retirement. This referral does not guarantee a disability retirement approval by GERS.

    3. Based on the Medical Certification, calculate how many hours are needed to cover your period of absence as determined by your medical provider. Please note that advance sick leave negatives must be covered by donors prior to any donated leave being applied to the period of absence, please ensure than enough donor applications are provided to avoid pay interruption, donated leave cannot be used to cover pay cycles already closed. Additionally, sick leave is an hour for hour donation. However, annual leave donations are adjusted by the salary of the donor.


    4. Seek donated leave to cover the hours needed and have each donor complete a Donated Leave Authorization Form.


    5. If the employee meets the criteria outline above, this request should be completed. Please be ready to electronically attach the Medical Certification and sufficient Donor Authorization Forms to cover the period of absence. A decision regarding your donated leave application will be provided within ten days of receipt of the submission.  Failure to attach the required documents will result in an immediate denial.

    This application can be completed by the employee recipient, family member of the employee recipient, or by the employee’s supervisor or Human Resources Department.

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    This application can be completed by the employee requesting leave, family member of the employee, employee’s supervisor or Human Resources Department.
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    • Agriculture
    • Education (Department of)
    • Board of Education
    • Career and Technical Education Board
    • Casino Control Commission
    • Collective Bargaining
    • Corrections Bureau
    • Economic Development Authority
    • Economic Research
    • Election System
    • Energy Office
    • Finance
    • Fire Service
    • Government Employees' Retirement System
    • Governor's Office
    • Health
    • Housing Authority
    • Housing Finance Authority
    • Human Services
    • Information Technology
    • Inspector General - V.I.
    • Internal Revenue
    • Juan Luis Hospital
    • Judicial Branch
    • Justice
    • Labor
    • Law Enforcement Planning Commission
    • Legislature
    • Licensing and Consumer Affairs
    • Lieutenant Governor's Office
    • Lottery
    • Magens Bay Authority
    • Management and Budget
    • Motor Vehicles
    • National Guard
    • Nurse Licensure
    • Personnel
    • Planning and Natural Resources
    • Police Department
    • Port Authority
    • Property and Procurement
    • Public Broadcasting System
    • Public Defender - Territorial
    • Public Employees Relations Board
    • Public Finance Authority
    • Public Services Commission
    • Public Works
    • Schneider Regional Medical Center
    • School Construction and Maintenance
    • Sports, Parks & Recreation
    • Taxicab Commission
    • Tourism
    • University of the Virgin Islands
    • Veterans Affairs
    • viNGN
    • VITEMA
    • Waste Management Authority
    • Water and Power Authority
    • West Indian Company
    • TEST
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    • St. Croix
    • St. John
    • St. Thomas
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    • Spouse
    • Parent (Biological)
    • Child (Biological, Adopted, Foster)
    • Sibling (Biological)
    • Other (Identified in a legally sufficient, duly executed living will of an incompetent or incapacitated employee)
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    Donor Forms

    Please ensure all of your donors have completed their online Donor Request Forms.

    Only online donor forms will be accepted.  

    Donor forms should be completed online at https://vi.jotform.com/201626124475956

    Please note: submission of donors does not guarantee transfer of the hours donated. 

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    Medical certifications can not be dated more than 30 days prior to the date of application.
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    Application Received
    • Applicant Withdrew
    • Application Received
    • Medical Certification form incomplete: Employee/ Physician signature and or date missing.
    • Medical Certification form incomplete: No diagnosis code, diagnosis narrative or symptoms given.
    • Medical Certification form incomplete: No return-to-work date provided.
    • We are trying to reach you. Please contact Karrelyn Blake (karrelyn.blake@dop.vi.gov), 340-774-8588 ext. 5105 or Charisma Lewis (charisma.lewis@dop.vi.gov), 340-774-8588 ext. 5147.    
    • Medical Certification form incomplete: Please contact Karrelyn Blake (karrelyn.blake@dop.vi.gov), 340-774-8588 ext. 5105 or Charisma Lewis (charisma.lewis@dop.vi.gov), 340-774-8588 ext. 5147.    
    • Medical Certification Form not submitted. Please contact Karrelyn Blake (karrelyn.blake@dop.vi.gov), 340-774-8588 ext. 5105 or Charisma Lewis (charisma.lewis@dop.vi.gov), 340-774-8588 ext. 5147.    
    • Decision Letter Pending Signature
    • Approval letter & Donor Schedule sent to Department of Finance for Leave Transfer
    • Approval Letter and Donor Schedule Sent to Agency HR for processing.
    • Decision Letter Sent
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