Request For Leave Or Approved Absence - Opm Form 71


Request for Leave or Approved Absence
2. Employee or Social Security Number (Enter only the
1. Name (Last, first, middle)
last 4 digits of the Social Security Number (SSN))
3. Organization
5. Family and Medical
4. Type of Leave/Absence
(Check appropriate box(es) below)
If annual leave, sick leave, or
Accrued Annual Leave
leave without pay will be used
under the Family and Medical
Restored Annual Leave
Leave Act of 1993, please provide
the following information:
Advanced Annual Leave
I hereby invoke my
Accrued Sick Leave
entitlement to Family
and Medical Leave for:
Advanced Sick Leave
Birth/Adoption/Foster Care
Illness/injury/incapacitation of requesting employee
Serious health condition of
spouse, son, daughter, or
Medical/dental/optical examination of requesting employee
Care of family member, including medical/dental/optical examination of family
Serious health condition of
member, or bereavement
Care of family member with a serious health condition
Contact your supervisor and/or
your personnel office to obtain
additional information about your
entitlements and responsibilities
Compensatory Time Off
under the Family and Medical
Leave Act. Medical certification of
Other Paid Absence
a serious health condition may be
(Specify in Remarks)
required by your agency.
Leave Without Pay
6. Remarks:
7. Certification:
I hereby request leave/approved absence from duty as indicated above and certify that such leave/absence is
requested 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 on this form may
be grounds for disciplinary action, including removal.
7a. Employee Signature
7b. Date
(If disapproved, give reason. If annual leave,
8a. Official Action on Request:
initiate action to reschedule.)
8b. Reason for Disapproval:
8c. Supervisor Signature
8d. Date
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
Local Reproduction Authorized
OPM Form 71
5 CFR 630
Rev. September 2009
Formerly Standard Form (SF) 71
Print Form
Save Form
Clear Form
Previous editions usable


00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal