FLORIDA DEPARTMENT OF ECONOMIC OPPORTUNITY

VOLUNTEER CERTIFICATON FOR ADMINSTRATIVE LEAVE
Associate: Please submit this form with your individual Attendance and Leave Report (timesheet) to your supervisor at the end of each monthly leave period. Supervisor: Attach these documents to the Monthly Absence Report to ensure Administrative Leave is properly credited, otherwise, personal leave and/or leave without pay will be charged.
Please print or type:
Part I - Associate and Supervisor Information
Name	Social Security Number
Division/Bureau	Cost Center Number
Work Telephone Number	SUNCOM
City
Supervisor's Name	Supervisor's Telephone Number
Part II - Organization Information
Name of Organization
Coordinator/Representative	Telephone Number
Log of Associate's Volunteer Participation:
Date
Time In
Time Out
Hours
Initial's
Part III - Certification
I certify that the above associate volunteered at this organization on the dates and times listed above.
Coordinator/Representative
Date	Associate
Date
Signature
Part IV - For Human Resource Management (HRM) Use Only
Approved Per Criteria
Disapproved Per Criteria
HRM Representative Signature
Date

INSTRUCTIONS
Use this form to document Administrative Leave used for training/orientation and the performance of volunteer service hours. Use a separate form for each monthly leave period and for each separate volunteer organization.
ASSOCIATE'S RESPONSIBILITIES
Fill out each section completely.
Part I (Associate and Supervisor Information)
Part II (Organization Information). Ask the organizations coordinator/representative to complete the appropriate section
Document, under "Log of Associate's Volunteer Participation," the Date, Time In, Time Out, and Hours you participated. Have the organization coordinator/representative initial each time that you participate.
Part III (Certification). Sign and date, and have the organization coordinator/representative also sign and date during your last visit to the organization within each monthly leave period.
Submit the original form with your Individual Attendance and Leave Report (timesheet) to your supervisor at the end of the monthly leave period.
SUPERVISOR'S RESPONSIBILITIES
Attach this form and the associate's Individual Attendance and Leave Report (timesheet) to the Monthly Absence Report at the end of each monthly leave period and send to:

Human Resource Management

Caldwell Building

107 E. Madison Street

Tallahassee, FL 32399-6545

DEO Form HRM-57 (11/00)

FLORIDA AGENCY FOR WORKFORCE INNOVATION

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2001-02-21

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FDLES J&B OIT