PTO Donation Request Form PTO Donation Policy: An employee may receive donated PTO of up to 40 hours annually Donated PTO may not be carried over
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PTO Donation Request Form
PTO Donation Policy: An employee may receive donated PTO of up to 40 hours annually. Donated PTO may not
be carried over from one calendar year to the next. The employee may only receive donated PTO for the following
reasons: extended bereavement, employee illness, and/or Acts of God. Any PTO donated, but not used by the
recipient-employee for the qualifying event, will be forfeited and not paid out. Unused PTO cannot be returned
to the donating employee.Note: PCM will consider the COVID-19 pandemic as an Act of God. Requests submitted for this reason will be
decided on an individualized basis, and after due consideration is given to all the facts and circumstances
surrounding the request, including the significant hardship faced by the receiving employee as well as the impact
donation will have on the donor.Date of request _______________________
Employee donating PTO: ____________________________________________ Facility: ___________________ Employee receiving donated PTO: _____________________________________ Facility: ___________________ Amount to be donated: _________hours (cannot exceed 40 hours)Reason for donation (must select one)
Extended bereavement
Employee illness
Act of God (specify): ________________________________Employee donating PTO: __________________________________________ __________________ Signature Date
Corporate use only:
Corporate staff reviewing request: __________________________________ __________________ Signature Date