3971, 2008, Request For Notification Of Abnsence
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1
2Request for or Notification of Absence
Employee's Name (Last, First, M.I.)
Employee ID
Date Submitted
No. of Hours Requested
PP
Year
Installation (For PM leave, show city, state, and ZIP code)
N/S Day
Pay Loc. # D/A Code
From Date
Hour
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
Annual
03
For FMLA Leave (Certification reviewed)
Yes
No
Holiday/AL Lv Exch
Tue
For COP Leave (CA1 on file)
04
Carrier 701 Rule
Begin Work
For Advanced Sick Leave (1221 on file)
Wed
LWOP (See reverse)
05
For Military Leave (Orders reviewed)
Lunch-Out
Sick (See reverse)
Thur
For Court Leave (Summons reviewed)
06
Late
Lunch-In
For Higher Level (1723 on file)
Fri
COP
07
Scheme Training Testing, Qualifying (Memo on file)
End Work
Other:
Sat
08
Remarks (Do not enter medical information)
Sun
Total Hours
09
Mon
I understand that the annual leave authorized in excess of amount available to me during the leave year will be changed to LWOP.
10
Employee's Signature and Date
Signature of Person Recording Absence and Date
Signature of Supervisor and Date Notified
Tue
11
Wed
Official Action on Application (Return copy of signed request to employee)
12
Approved, not FMLA
Approved FMLA, Pending
Approved, FMLA
Signature of Supervisor and Date
Thur
Documentation Noted on Reverse.
(See Publication 71)
13
Disapproved (Give reason):
Fri
Ineligible for FMLA (Estimate eligibility date):
Continued on Reverse
14
3971
Warning: The furnishing of false information on this form may result in a fine of not more
PS Form
, March 2008 (Page 1 of 2) PSN 7530-02-000-9136
than $10,000 or imprisonment of not more than 5 years, or both. (18 U.S.C. 1001)
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