STATE EMPLOYEE-TO-EMPLOYEE LEAVE DONATION PROGRAM
This packet contains information and all forms necessary to request leave from the
Employee-to-Employee Leave Donation Program:
1. Fact Sheet for the Employee-to-Employee Leave Donation Program– Contains
general information about donating and receiving leave from the Employee-to-
Employee Leave Donation Program.
2. Employee-to-Employee Leave Donation Program - Request Form (MS405) –
• Part I – To be completed by employee donating leave and their Agency
Appointing Authority
• Part II - To be completed by employee receiving leave and their Agency
Appointing Authority
3. Employee-to-Employee Leave Donation Program - Medical Certification Form
(MS402-EE) – Please have your treating physician(s) complete; submit the medical
form with Form MS 405 and the HIPAA form to your HR Office.
4. Authorization Form for Review of Records & Information (HIPAA Form) – Please
sign, date and submit, with the MS 402 and MS 405, to your HR Office.
5. Employee-to-Employee Leave Donation Program – Medical Documentation –
Provides examples of medical records that should be provided by your treating
physician(s) to support only the dates for which you are requesting leave. Have
physician provide you with as much additional medical documents as possible for the
period of leave that is being requested.
Medical records that address and support your work absence are the best documentation
to provide for favorable consideration of your request. For example, if you need leave to
cover your absence from January 1 to January 15, ask your treating physician(s) to
submit actual medical records that address the period from January 1 to January 15.
*If your request is for surgery, proof of surgery must be provided upon your initial
request.
*If your request is for birth of a child, proof and type of birth (normal or C-section) is
required.
INSTRUCTIONS FOR SUBMITTING AN
EMPLOYEE-TO-EMPLOYEE DONATION LEAVE REQUEST
MEDICAL RECORDS*
STATE EMPLOYEE-TO-EMPLOYEE LEAVE DONATION PROGRAM
FOR EMPLOYEES DONATING LEAVE TO OTHER EMPLOYEES:
• Employees may voluntarily donate unused annual, sick or personal leave to another employee.
• An employee who donates sick leave to another employee must maintain a sick leave balance of at
least 240 hours after the donation is deducted.
• An employee who donates leave shall designate the recipient of the leave.
• If an employee who receives leave does not use all of the donated leave, the remaining hours of leave
shall be restored to the employee(s) who made the donation, by their Appointing Authority (new).
To d
onate leave to another employee, please complete Part I of the State Employees’ Leave Donation
Form (MS405) and submit the form to your HR Office. You should also provide a copy of the form to the
employee to whom you are making the donation. The form is available from your HR Office or on the
Department of Budget and Management website at www.dbm.maryland.gov
.
FOR EMPLOYEES RECEIVING LEAVE FROM OTHER EMPLOYEES:
To qualify for leave from the Employee-to-Employee Leave Donation Program, an employee must:
• have exhausted all available annual, personal, sick and compensatory leave because of:
1) a personal serious and prolonged medical condition that exists at the time the leave is donated; or
2) a catastrophic illness or injury of a member of the employee’s immediate family for whom the
employee is needed to provide direct care. Catastrophic illness or injury is defined as a condition
that is incapacitating or life threatening as certified by a health care provider. An employee may
use leave from another employee to care for a family member only after obtaining approval from the
employee’s appointing authority. The appointing authority’s approval is discretionary and denia
l
m
ay be based on any reason which is consistently applied and is not illegal or unconstitutional.
• qualify for the use of sick leave under the requirements of the employee’s personnel system;
• must provide sufficient medical documentation to substantiate absence for the time period covered by
the Employee-to-Employee Leave request;
• in all likelihood be able to return to work;
• have received less than 2,080 hours of leave from the Leave Bank and the Employee-to-Employee
Leave Donation Programs; and
• not have used more than 16 continuous months of leave from the Leave Bank, Employee-to-Employee
Leave Donation Program and all other forms of paid leave.
To re
quest leave from another employee, please complete Part II of the State Employees’ Leave Donation
Form (MS405) and submit the form to your HR Office. You must also have the treatment provider complete
an Employee-to-Employee Leave Donation Program Medical Certification Form (MS402-EE) and provide
medical records that address the absence for which Employee-to-Employee Leave is requested. The forms
are available from your HR Office or on the Department of Budget and Management website at
www.dbm.maryland.gov
. Please submit completed forms and medical documentation to your HR Office.
(Rev. 2/2023)
FACT SHEET
EMPLOYEE-TO-EMPLOYEE LEAVE DONATION PROGRAM - REQUEST FORM
Name of Donating Employee*:
W# of Donating Employee*:
State Hire Date:
* Your full Name and Workday Number (W#) are required to help verify your identity. Failure to provide it may result in delays and/or rejection of this
request. This information is kept confidential.
Donating Employee’s Agency Name:
Agency Division:
RECEIVING EMPLOYEE’S INFORMATION:
Name of Employee:
Employee’s Agency Name:
Employee’s W#:
TYPE OF LEAVE DONATED: TOTAL HOURS DONATED:
LEAVE BALANCE AFTER
DONATION:
[ ] SICK**
[ ] ANNUAL
[ ] PERSONAL
I understand that if the employee to whom I am donating leave does not use the leave for any reason, the unused
donated leave shall be returned to my leave balances by my Appointing Authority.
Signature:
Date:
** If you are donating sick leave, you must maintain a balance of at least 240 hours of sick leave after
the donation is deducted.
ANNUAL/PERSONAL LEAVE CERTIFICATION: I have reviewed this employee’s leave balances and affirm that s/he
has sufficient annual/personal leave to make this donation.
S
ICK LEAVE CERTIFICATION: I have reviewed this employee’s sick leave balance. I affirm that s/he will have a sick
leave balance of at least 240 hours after this donation. As the Appointing Authority/Designee for the employee making
the above leave donation, I certify this donation is in compliance with COMAR 17.04.11.22 C (3).
_
______________________________________________ _________________________
APPOINTING AUTHORITY/DESIGNEE DATE
(Per COMAR 17.04.11.22 C (11) The appointing authority of an employee who donates leave shall adjust the donating
employee’s leave balance before forwarding a copy of the MS 405 form to the receiving employee’s appointing authority. If
the receiving employee is denied the use of donated leave, the receiving employee’s appointing authority shall notify the
donating employee’s appointing authority within 7 days of the denial, and the donating employee’s appointing authority shall
restore the leave balance of the donating employee within 14 days of notification from the receiving employee’s appointing
authority.)
*****************NOT VALID WITHOUT TIMEKEEPER CERTIFICATION******************
Hrs of selected LEAVE DONATED were deducted from balance on _________ by __________________________/______
Print Name! (!Required) / Initials
Page 1 of 2 MS 405 (Rev.2/2023)
PART I - TO BE COMPLETED BY DONATING EMPLOYEE
(Please TYPE or PRINT with black or blue Ink)
CERTIFICATION OF LEAVE FOR DONATING EMPLOYEE –
TO BE COMPLETED BY APPOINTING AUTHORITY/DESIGNEE
EMPLOYEE-TO-EMPLOYEE LEAVE DONATION PROGRAM - REQUEST FORM
Name*: Workday #*: W ___ ___ ___ ___ ___ ___ ___
* Your full Name and Workday Number (W#) are required to help verify your identity and process your Request. Failure to provide it may result in delays and/or
rejection of your request. This information is kept confidential.
Job Title and brief description of duties:
Home Address:
City/State/Zip:
Agency Name:
Request Type:
□
New
□
Extension
Reason for Request:
□ An illness or disability of the employee due to a serious and prolonged medical condition that existed at the time
the leave was donated; or
□
A catastrophic illness or injury of a member of the employee's immediate family for whom the employee is needed
to provide direct care**.
**For family member please provide - Name: Relationship:
**Describe care to be provided:
Signature: Date:
Leave Bank/Donation Coordinator: Email:
Phone #: Fax #: Employee Hire Date:
Last Day Employee Worked: ___________ Dates to Cover: From: ___________ Through: ___________
Donations Received: _________ Hrs Hours Needed: __________ Hrs
Is employee on FMLA leave? No □ Yes □ If Yes, provide end date of current FMLA:
Has the employee been seen by the State Medical Director? No
□
Yes
□ If Yes, provide copy of SMD Report
Leave Coordinator’s Signature: Date:
A
s the Appointing Authority/Designee for the employee receiving the leave donation, I certify that this employee has
exhausted all forms of annual, sick, personal and compensatory time because of a serious and prolonged medical condition.
Approval will not cause the employee to exceed 2,080 hours of leave from the Leave Bank and/or Employee-to-Employee Leave
Donation Programs during his/her entire State employment. Approval will not cause the employee to exceed 16 months of
continuous leave, when combined with all other forms of paid leave. As the appointing authority or designee for this employee,
I have reviewed the employee’s records and I certify that this request meets all of the criteria specified in this Section.
______________________________________________________________ ______________________________________
Signature of Appointing Authority or Designee Date
Page 2 of 2 MS 405 (Rev. 2/2023)
MUST BE COMPLETED BY AGENCY LEAVE BANK/DONATION COORDINATOR
MUST BE COMPLETED BY APPOINTING AUTHORITY/DESIGNEE
PART II - TO BE COMPLETED BY EMPLOYEE RECEIVING LEAVE DONATIONS
(Please TYPE or PRINT with Black or Blue ink)
STATE EMPLOYEE-TO-EMPLOYEE LEAVE DONATION PROGRAM
EMPLOYEE’S NAME:
PATIENT’S NAME (if not employee):
DIAGNOSIS(ES):
ICD 10 CODE(S) (Required):
SUMMARY OF TREATMENT(S) & PROCEDURE(S):
START DATE OF CURRENT INCAPACITY:
SURGERY DATE (IF APPLICABLE):
HOSPITALIZATION DATE(S) (IF APPLICABLE):
FROM: TO:
DATE EMPLOYEE IS LIKELY TO RETURN TO FULL DUTY (REQUIRED): _________________
********************************************
*PLEASE COMPLETE THIS SECTION ONLY IF EMPLOYEE CAN RETURN IN A MODIFIED
CAPACITY*
MODIFIED RETURN DATE (IF APPLICABLE): __________________
PROVIDE RESTRICTIONS FOR MODIFIED DUTY (REQUIRED WITH A MODIFIED DATE):
_______________________________________________________________________________________________
_
______________________________________________________________________________________________
********************************************
PHYSICIAN’S NAME (PRINT) PHYSICIAN’S PHONE NUMBER
PHYSICIAN’S SIGNATURE (REQUIRED) DATE FORM COMPLETED
(PLEASE ATTACH REQUIRED MEDICAL VERIFICATION OF SURGERY)
MS 402-EE
(Rev. 2/2023)
Failure to provide sufficient medical documentation may delay the processing of this request. This
information shall be treated as a
confidential medical record; it shall not be placed in the employee’s
personnel file.
MEDICAL CERTIFICATION FORM
TO BE COMPLETED BY TREATING PHYSICIAN
STATE EMPLOYEE-TO-EMPLOYEE LEAVE DONATION PROGRAM
In most situations, your leave request will be evaluated without benefit of a
personal examination. Please have your health care provider(s) submit appropriate
medical documentation to support your request. The best thing to submit for a
favorable consideration is medical documentation that addresses ONLY the
period of time for which the leave is requested.
Listed below are examples of the type of medical documentation that should be
submitted, if applicable:
1)
Office Visit Notes
2)
Hospital Records (Operative Report & Discharge Summary)
3)
Physical & Diagnostic Findings
4)
Physician’s Statement Of Current Disability, Symptoms And Physical
Limitations (to explain why you cannot perform your job duties) and
Prognosis
5)
Laboratory Reports (EEG, Myelogram, Angiography, Cat Scan, Etc.)
6)
Reports Of X-Rays As Read By Examining Physician
7)
Physical Therapy Notes
8)
Reports from Specialists
9)
Date and proof of surgery or other Procedure
10)
For Pregnancy Cases, Expected Due Date and Actual Delivery Date,
Type of Delivery and Copy of Antepartum Record; a birth certificate is
not medical proof for birth.
*You must also provide sufficient medical documents to allow your request to be
reviewed appropriately if your request is to care for a family member.
Rev. 2/2
023
MEDICAL DOCUMENTATION*
STATE EMPLOYEE-TO-EMPLOYEE LEAVE DONATION PROGRAM
A. Identification: This document authorizes the use and/or disclosure of confidential protected health information
about the following person; this document is not used to request additional medical records or information
on the patient’s behalf.
E
mployee’s Name: _______________________________________ Date of Birth: _________________
Patient’s Name
(if not the employee): ____________________________ Date of Birth: __________________
B. Directions for Release:
I authorize the individual or company identified below in Section B.1b to release and/or use protected health
i
nformation pertaining to the individual listed in Section A to the individual(s) identified in Section B.1a.
B.1a. I authorize the disclosure of information to:
o My Appointing Authority or Designee
o State of Maryland Employee-To-Employee Leave Donation Program
B.1b. I authorize the release of information from:
o (Specify Health Care Provider) _______________________________________________________
o State Medical Director
B.2. Information to be released: I authorize the disclosure and/or use of any information from my
m
edical records relating to the condition(s) for which I am seeking leave.
B.
3. Purposes: I authorize the disclosure and/or use for the following reason(s):
(a
) t
o determine my eligibility for leave from the State of Maryland Employee-To-Employee
Leave Donation Progra
m
B.
4. I am asking that you NOT provide any genetic information when responding to this request for medic
al
i
nformation. Genetic information, as defined by the Genetic Information Nondiscrimination Act of 2008,
includes an individual's family medical history, the results of an individual's or family member's genetic
tests, the fact that an individual or an individual's family member sought or received genetic services,
and genetic information of a fetus carried by an individual or an individual's family member or an
embryo lawfully held by an individual or family member receiving assistive reproductive services.
C. Right to Revoke: I understand that I may revoke this authorization at any time except to the extent that action
has already been taken in reliance upon it. This authorization will expire one year after the date it is signed. To
r
evoke the authorization, I must contact, in writing: Jennifer Hine, Director, Personnel Services, Department of
Budget and Management, 301 W. Preston Street, Room 705, Baltimore, MD 21201 or via Fax at 410-333-5440.
D. Authorization and Signature: I authorize the review of my confidential protected health information, as
described in my directions in Section B. I understand that this authorization is voluntary, the information to be
di
sclosed is protected by law and the disclosure will conform with my directions. The information that is us
ed
and/
or disclosed pursuant to this authorization may be redisclosed by the recipient unless the recipient i
s
c
overed by Maryland law which prohibits redisclosure or other laws limiting the use and/or disclosure of my
confidential protected health information.
I
have read the contents of this authorization and I confirm that the contents are consistent with my directions.
I understand that by signing this form, I am authorizing the review and/or disclosure of my confident
ial
protected health information for determining my eligibility for leave.
________________________________ ________________________________ ___________________
Employee Signature Patient Signature
(if not employee) Date
(Rev. 2/2023)
AUTHORIZATION FORM FOR REVIEW OF RELEASED RECORDS AND INFORMATION
