CITY OF MINNEAPOLIS

DONATION PROGRAM FOR SERIOUS ILLNESS/INJURY

INFORMED CONSENT FOR RELEASE OF DATA

Pursuant to the City of Minneapolis' Donation Program for Serious Illness or Injury I have requested that fellow employees of the City of Minneapolis donate vacation, sick leave and or compensatory time, into my sick leave bank. I understand that pursuant to the Minnesota Government Data Practices Act, in soliciting donations of leave time from other City of Minneapolis employees, that the nature of the serious illness or injury involved is private data that may not be disclosed by the City of Minneapolis to others, including to other City of Minneapolis employees, without my informed consent.

Check box below that applies:

____ I DO NOT authorize the City of Minneapolis and/or my immediate supervisor and/or Department Head to disclose to other City of Minneapolis employees the nature of the serious illness or injury involved.

____ I DO authorize the City of Minneapolis and/or my immediate supervisor and/or Department Head to disclose to other City of Minneapolis employees the following information:

Nature of Illness/Injury:______________________________________________________

Date Illness/Injury Began:____________________________________________________

Anticipated Return to Work:__________________________________________________

_____________________________________ _______________________________

Employee signature Date

Last updated Sep. 27, 2011