SERV Program Leave Request Form Type of organization where

COMMONWEALTH OF MASSACHUSETTS
HUMAN RESOURCES DIVISION
SERV PROGRAM FORM
Updated September 2011
State
Employees
Responding as
Volunteers Program
SERV Program Leave Request Form
Please use code “VSL” for all SERV time on your timesheet.
Type of organization where you want to volunteer in Massachusetts (Check)
Public School including Charter Schools
Other educational volunteering
Youth Mentoring
Environment
Health
Human Services
Public Safety
Your Employee ID:
Your Name:
Your State Agency:
Your Official Job Title:
Work Address:
Work Phone:
SERV Organization Name:
SERV Address:
SERV Program Liaison:
Phone #:
Description of specific volunteer service to be provided:
Please share the SERV Guidelines with the volunteer organization prior to your
shift:
SERV website: www.mass.gov/serv
SERV Guidelines:
http://www.mass.gov/Eoaf/docs/hrd/policies/leave/serv_guidelines.doc
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State
Employees
Responding as
Volunteers Program
COMMONWEALTH OF MASSACHUSETTS
HUMAN RESOURCES DIVISION
SERV PROGRAM FORM
Updated September 2011
PROPOSED VOLUNTEER SCHEDULE
One request must be submitted for all activities within a calendar month.
Specific Date(s):
Day(s) of Week:
Hours From:
To:
I verify that if approved to participate in the SERV Program, I will follow all
guidelines and regulations of HRD, my agency and the program or public school
in which I volunteer. I will bring a SERV Verification Form with me to my volunteer
shift and the volunteer organization will sign the form which I then send to human
resources upon my return to the office.
Your Signature: ____________________________ Date:
SUPERVISOR REVIEW
Request approved:
Request denied:
Reason for denial (check one or more):
Employee not eligible
Nonprofit not eligible/not approved
Volunteer activity not acceptable
Insufficient notice
Operational needs of the agency
Other (describe)
Supervisor Signature:____________________Date:
AGENCY HEAD or DESIGNEE REVIEW (usually Human Resources)
Agencies may add more levels of approval if applicable.
Request approved:
Request denied:
Comments:
__________________________________
Agency Head/Designee Signature
Date
NOTE: The signed, completed form should be filed in the University’s Human Resources
Office, 325 Whitmore Administration Building, with the completed Leave Verification Form.
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