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donated eight (8) hours of vacation leave to the Shared Leave Bank during benefits open
enrollment. Employees must have exhausted all other paid leave (sick, vacation, holiday, short-
term disability) before receiving shared leave donations.

Applying for shared leave donations requires completion of two forms: the “Request to
Receive Donated Leave” and “Shared Leave Medical Certification” forms which can be found
on the Employee Center at http://wshome.cityofws.org/wshome/forms/forms. The medical
certification form must be completed by the treating physician for the serious or catastrophic
medical condition for which the employee is requesting leave. All medical information received
is confidential.

Employee may receive up to 12 weeks of shared leave in a 12 month period, and any
unused shared leave remaining in a recipient’s leave accrual upon return to work will be returned
to the Shared Leave Bank.

Donor

Employees wishing to donate to the Shared Leave Bank during annual enrollment must
donate 8 hours of sick time to the Shared Leave Bank. If donating leave at any point other than
annual enrollment, donors must donate at least 8 hours of sick time and a matching amount of
vacation time. Donors donating at any point other than annual enrollment must retain at least 40
hours of sick time and 40 hours of vacation time after the donation is approved.

Employees may donate leave by filling out the “Shared Leave Donor Authorization”
form located on the Employee Center at http://wshome.cityofws.org/wshome/forms/forms.
Employees are restricted from donating leave to immediate supervisors who conduct their
performance appraisals. Terminating employees may donate accrued vacation and/or holiday
time to another employee or the shared leave bank, but may not donate sick time.

The City of Winston-Salem reserves the right to modify or terminate the Shared Leave
Program at its sole discretion, and at any time.

M. City of Winston-Salem Notice of Privacy Information Practices

This notice describes how your medical information may be used and disclosed and how
you can get access to this information. Please read it carefully.

Introduction

A federal regulation, the Health Insurance Portability and Accountability Act of 1996,
also known as the HIPAA Privacy Rule, requires the City to provide a detailed notice in writing
of its privacy practices. This notice is long because the HIPAA Privacy Rule requires the City to
address a number of specific issues in its notice of privacy information practices.

City of Winston-Salem Employee Handbook November 2014 Revision 38