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City of <br /> amsey <br /> <br />I <br />I <br /> <br />ADMINISTRATIVE SERVICES <br /> <br />15153 Nowthen Boulevard N.W. <br />Ramsey, MN 55303 <br />wxvw.ci.ramsey.mn.us <br /> <br />Phone: (612) 427-1410 <br />Fax: (612)427-5543 <br />TDD: (612) 427-8537 <br /> <br /> , request vacation time donations from employees in <br /> (pfintnmne) <br /> <br />accordance with the City of Ramsey's Administrative Policy on Donation of Vacation Leave. <br /> <br /> Supporting medical data must be submitted with this request stating Physician's recommendation <br />on length of leave due to illness/injury. The medical data we collect from you will be used by the City <br />Administrator and Administrative Services Manager to evaluate your request for vacation leave donation with <br />regard to Ramsey's Administrative Policy on Donation of Vacation Leave. This information, which will be <br /> <br />I <br />I <br /> <br />maintained as part of your personnel record, is private and will not be shared with anyone other than as <br />specified above except with your informed consent. If you have any questions about the information we <br />ask you to provide, please contact the Administrative Services Manager. <br /> <br />Employee Signature <br /> <br />Date <br /> <br /> I wish to have the reasons for my request shared with employees. I understand that this is private <br />data and can only be given with my release. <br /> <br />No, do not release the reason <br /> <br />Yes,please release the reason for my request (optional) <br /> <br />The reason I request vacation leave donations is: <br /> <br />i Administrative Services Manager Med Info Rec'd CityAdministrator 6/99 <br /> <br /> <br />