Director/Senior Director Change to FTO

As you are aware, Directors and Senior Directors will be moving from a Paid Time Off (PTO) plan to a flexible time off (FTO) plan effective 1/1/2023.

This form is to confirm that each leader understands the change and does not have any remaining questions that they would like answered prior to 1/1/2023. If there are questions remaining, please reach out to Brooke Spencer before completing this form.

This form will also provide HR and Payroll with a final response as to how you would like to receive your PTO payout.

Leader's Name Leader's Name * First Last
Leader's Email
EE Number *
I understand that effective 1/1/2023 Mercyhealth Directors/Senior Directors are transitioning to the Flexible Time Off (FTO) model and that my accrued and unused PTO as of 12/31/2022 will be paid out to me in January 2023 based on my selection below. Furthermore, I understand that under the FTO model I am no longer going to accrue PTO while in my Director/Senior Director role beginning on 1/1/2023. *

I understand that effective 1/1/2023 Mercyhealth Directors/Senior Directors are transitioning to the Flexible Time Off (FTO) model and that my accrued and unused PTO as of 12/31/2022 will be paid out to me in January 2023 based on my selection below. Furthermore, I understand that under the FTO model I am no longer going to accrue PTO while in my Director/Senior Director role beginning on 1/1/2023. By checking this box, I acknowledge that this transition will occur.
How do you want your PTO payout to be paid to you? *

How do you want your PTO payout to be paid to you? Full (100%) PTO payout on off-cycle January 12, 19, or 20 (depending on entity) check. Full (100%) PTO payout rolled into my Mercy Health Corporation 403b account on January 12, 19, or 20 (depending on entity), up to the annual IRS limit. The remainder will be paid out on the off cycle-check. Partial PTO payout rolled into my Mercy Health Corporation 403b account, up to the IRS limit, and partial payout on off-cycle January 12, 19, or 20 (depending on entity) check.

HR and Payroll will use this form to update your PTO payout method, so you do not need to take any additional action after completing this form.
Please indicate the % of your payout that you would like added to your 403b account? Note, the remaining % will be added to your off-cycle January 12, 19, or 20 (depending on entity) check. *

HR and Payroll will use this form to update your PTO payout method, so you do not need to take any additional action after completing this form.
By signing below, you signify that you are the individual listed on this form and that the above PTO payout method is how you want HR and Payroll to payout your PTO. *

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