Usps 3971, 2001, Request For Or Notification Of Absence
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1Request for or Notification of Absence
Employee's Name (Last, First, M.I.)
Year
Social Security No.
Date Submitted
No. of Hours Requested
PP
Installation (For PM leave, show city, state, and ZIP code)
N/S Day
From Date
Hour
Pay Loc. #
D/A Code
Day Init. Hours
Sat
01
Time of Call or Request
Scheduled Reporting Time
Employee Can Be Reached At (if needed)
Thru Date
Hour
Sun
No Call
02
Type of Absence
Documentation (For official use only)
Revised Schedule for (Date)
Approved in Advance
Mon
03
Annual
Yes
No
For FMLA Leave (Certification reviewed)
Tue
Carrier 701 Rule
For COP Leave (CA 1 on file)
04
Begin Work
Wed
LWOP (See reverse)
For Advanced Sick Leave (1221 on file)
05
Sick (See reverse)
For Military Leave (Orders reviewed)
Lunch-Out
Thur
Late
For Court Leave (Summons reviewed)
06
Lunch-in
Fri
COP
For Higher Level (I 723 on Me)
07
Other:
Scheme Training Testing, Qualifying (Memo on file)
End Work
Sat
Remarks (Do not enter medical information)
08
Total Hours
Sun
09
I understand that the annual leave authorized in excess of amount available to me during the leave year will be changed to LWOP.
Mon
Employee's Signature and Date
Signature of Supervisor and Date Notified
Signature of Person Recording Absence and Date
10
Tue
1 1
tic
Official Action on Application (Return copy of signed request to employee)
Wed
Signature of Supervisor and Date
12
Approved, not FMLA*
Approved, FMLA
Approved FMLA, Pending
(See Publication 71)
Documentation Noted on Reverse.
Thur
13
Disapproved (Give reason):
Fri
14
Ineligible for FMLA (Estimate eligibility date):
Continued on Reverse
3971,
PS Form
April 2001 (Page I of 2)
Warning. The furnishing of false information on this form may result in a fine of not more
than $1 0,000 or imprisonment of not more than 5 years, or both. (18 U.S.C. 1001)
Leave Types
During This Absence, I Was Incapacitated for Duty by.
(Information Only)
PP
Year
Time Card
PSDS
Sickness
Undergoing Medical, Dental, or
Leave Type
Code
Code
Optical Examination or Treatment
On-the-Job Injury
-
Day Init. Hours
-
(Job related)
AL-FMLA
55/01
32
Sat
Off-the-Job injury
SL-FMLA
56/02
33
Undergoing Medical, Dental, or
01
LWOP - FMLA - Part Day
Pregnancy and Confinement
59/05
36
Optical Examination or Treatment
Sun
LWOP - FMLA - Full Day
60/06
37
(Not job related)
Exposed to a Contagious Disease
02
LWOP Lieu of Sick Leave
-
59/60
20
Mon
LWOP Proffered
-
59/60
21
During This Absence, I Was Unavailable for Duty Because-,
03
22
LWOP Personal Reasons
-
59/60
Tue
Sick Leave for Dependent Care
Placement of a Child with Employee
LWOP Part Day
-
59
23
04
for Adoption or Foster Care
LWOP Full Day
Birth of Child - Bonding
-
60
23
Wed
LWOP AWOL
-
59/60
24
Additional Information Regarding Denial of Leave Protection Under FMLA:
05
LWOP IOD (Not FMLA) - OWCP
-
49
25
Thur
Employee Not Eligible - Less than 1250 Hours Worked.
LWOP Maternity
-
59/60
26
06
LWOP Suspension
-
Employee Not Eligible -- Not Employed with USPS 1 Year
59/60
27
Fri
LWOP Union Official
-
84
28
Employee Has Exhausted FMLA Entitlement in Current Leave Year.
07
LWOP Suspension Pending
-
Sat
Absence Not for a Covered Condition.
Termination
59/60
29
08
Continuation of Pay USPS
-
71
03
Absence Not for a Covered Family Member.
Sun
Continuation of Pay USPS-FMLA 71/03
-
34
Requested Documentation Not Provided,
09
Continuation of Pay FMLA-IOD-OWCP 49/04
35
Mon
Documentation Provided. Does Not Meet Criteria for FMLA Protection.
Court Duty
61
04
10
Additional Documentation Required
Military Leave
67
05
I
Tue
89.
Postmaster's Organization
08
1 1
Blood Donor Leave
69
09
Wed
Other Paid Leave
86
10
12
Convention Leave
66
12
Thur
Acts of God
78
13
13
Veteran's Funeral
10
86
Privacy Act: The collection of this information is authorized by 39 USC 401. 1001, 1003. 1005; 5
F d
Relocation
80
15
JSC 8339; and Public Law 103-3. This information will be used to grant or deny your request for
14
official leave from Postal Service duty. It may be disclosed under the routine uses given in Privacy
Civil Defense
77
16
Act system notices USPS 050.020 and USPS 120.070 (see appendix of Administrative Support
Civil Disorder
17
81
Manual or, if you wish to obtain a copy of these notices contact your personnel office). Completion
Voting Leave
85
18
of this form is voluntary. If this information is not provided. Official leave may not be granted.
3971,
PS Form
April 2001 (Page 2 of 2)
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