Request to receive hours from the VUMC flexPTO Donate Program

Donations must be made prior to June 1 of the current fiscal year to be received.
NOTE: The donated hours will not immediately appear in your flexPTO bank. It may take up to 2 pay periods for to appear in your flexPTO bank.

Name Name First Last
Employee ID
Department
I attest that:

I am experiencing a hardship due to a qualifying serious personal or family medical situation as defined in the flexPTO Share program.
I have applied for leave under the VUMC FMLA program. (Initial here)
I am not receiving pay from other benefits such as short-term disability, long-term disability or worker’s compensation. (Initial here)
I am eligible for flexPTO under the VUMC flexPTO Donate program. (Initial here)
I have not received 80 hours of flexPTO under the donate program this fiscal year, which is July through June. (Initial here)
In accordance with the flexPTO Donate program, I would like to receive donated flexPTO transferred to my flexPTO balance. I understand that the transfer is subject to the availability of days and eligibility. I verify that I meet the above conditions and understand that hours may not be solicited directly by me from individual employees.
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Date Date / MM / DD YYYY
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Request to receive hours from the VUMC flexPTO Donate Program

Request to receive hours from the VUMC flexPTO Donate Program

I attest that: