Fillable Opm-71 Form - Request For Leave Or Approved Absence printable pdf download

Request for Leave

or Approved Absence

2. Employee or Social Security Number

1. Name (Last, first, middle)

3. Organization

Type of Leave/Absence

Family and Medical Leave

Date

Time

Check appropriate box(es) and

Total Hours

If annual leave, sick leave, or leave without

enter date and time below)

From

pay will be used under the Family and

Accrued annual leave

Medical Leave Act of 1993 (FMLA), please

Restored annual leave

provide the following information:

Advance annual leave

I hereby invoke my entitlement

Accrued sick leave

to family and medical leave for:

Advance sick leave

Birth/Adoption/Foster care

Purpose:

Illness/injury/incapacitation of requesting employee

Serious health condition of

spouse, son, daughter, or parent

Medical/dental/optical examination of requesting employee

Care of family member, including medical/dental/optical examination of family member, or

Serious health condition of self

bereavement

Care of family member with a serious health condition

Contact your supervisor and/or your

Other

personnel office to obtain additional

information about your entitlements and

responsibilities under the FMLA. Medical

Compensatory time off

certification of a serious health condition

Other paid absence

may be required by your agency.

(specify in remarks)

Leave without pay

6. Remarks

Certification: I certify that the leave/absence requested above is for the purpose(s) indicated. I understand that I must comply with my

employing agency's procedures for requesting leave/approved absence (and provide additional documentation, including medical

certification, if required) and that falsification of information on this form may be grounds for disciplinary action, including removal.

7a. Employee signature

7b. Date signed

8a. Official action on reques t

(If disapproved, give reason. If annual leave,

Approved

Disapproved

initiate action to reschedule.)

8b. Reason for disapproval

8c. Signature

8d. Date signed

Privacy Act Statement

Section 6311 of title 5, United States Code, authorizes collection of this information. The primary use of this information is by

management and your payroll office to approve and record your use of leave. Additional disclosures of the information may be: To the

Department of Labor when processing a claim for compensation regarding a job connected injury or illness; to a State unemployment

compensation office regarding a claim; to Federal Life Insurance or Health Benefits carriers regarding a claim; to a Federal, State, or

local law enforcement agency when your agency becomes aware of a violation or possible violation of civil or criminal law; to a Federal

agency when conducting an investigation for employment or security reasons; to the Office of Personnel Management or the General

Accounting Office when the information is required for evaluation of leave administration; or the General Services Administration in

connection with its responsibilities for records management.

Public Law 104-134 (April 26, 1996) requires that any person doing business with the Federal Government furnish a social security

number or tax identification number. This is an amendment to title 31, Section 7701. Furnishing the social security number, as well as

other data, is voluntary, but failure to do so may delay or prevent action on the application. If your agency uses the information furnished

on this form for purposes other than those indicated above, it may provide you with an additional statement reflecting those purposes.

Office of Personnel Management

OPM Form 71

Local Reproduction Authorized

5 CFR 630

June 2001

Formerly Standard Form (SF) 71

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Opm-71 Form - Request For Leave Or Approved Absence

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