The Queen's Health System's Annual Employee Campaign

PTO DONATION

Employees may make an irrevocable election to donate between 4 to 40 hours of PTO each calendar year to one or more of the charitable organizations designated by Queen’s. There is NO proration for part-time employees. PTO donation requests will be accepted at any time during the calendar year.

You may elect to donate a minimum of 4 hours and up to a maximum of forty (40) hours of your PTO hours to one or more of Queen’s designations below.

By submitting this deduction authorization form, you understand the following:

Your election to make this PTO donation is irrevocable.
Your PTO hours will be reduced as a one-time deduction from your next available paycheck after processing.
The amount donated will be the gross cash value of those PTO hours multiplied by your hourly rate of pay.
Your PTO donation is subject to all applicable taxes e.g. Federal, State, Social Security, etc. to be paid by the employee.

Please indicate below the amount of PTO hours that you wish to donate.

The total combined amount of your PTO donation must be a minimum of 4 hours up to a maximum of 40 hours.

Queen's ‘Ohana to ‘Ohana Fund

The Queen's Health Systems

The Queen's Medical Center

The Queen's Medical Center - Kahi Mohala

The Queen's Medical Center - Wahiawa

The Queen's Medical Center - West O‘ahu

Queen’s North Hawai‘i Community Hospital

Queen’s University Medical Group

Molokai General Hospital

QMC West Hawai‘i Construction Project

Total (max. 40 hours)

Title

First Name

Last Name

Address

City

State

Zip Code

Employee ID#

Department Name

Location

Work Phone #

Work Email

Acknowledgement

By submitting this form, I agree and acknowledge that I have read the information above and that my PTO donation is subject to all applicable taxes e.g. Federal, State, Social Security, etc. to be paid by the employee.