Fillable Standard Form 71 - Request For Leave Or Approved Absence 1997 printable pdf download

REQUEST FOR LEAVE OR APPROVED ABSENCE

2. EMPLOYEE OR SOCIAL SECURITY NUMBER

1. NAME (Last, First, Middle Initial)

3. ORGANIZATION

4. TYPE OF LEAVE/ABSENCE

DATE (mm/dd/yyyy)

TIME

TOTAL

5. FAMILY AND

(Check appropriate box(es) below.)

From:

To:

From:

To:

HOURS

MEDICAL LEAVE

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

Advance Annual Leave

information:

Accrued Sick Leave

I hereby invoke my

entitlement Family and

Medical Leave for:

Advance Sick Leave

Birth/Adoption/Foster Care

Purpose:

Medical/dental/optical examination of requesting employee

Other

Serious Health Condition of

Care of family member/bereavement, including medical/dental/optical

Spouse, Son, Daughter, or

examination of family member

Parent

Serious Health Condition of

Compensatory Time Off

Self

Other Paid Absence

Contact your supervisor and/or your

personnel office to obtain additional

(Specify in Remarks)

information about your entitlements

and responsibilities under the Family

Leave Without Pay

and Medical Leave Act of 1993.

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 of

information on this form may be grounds for disciplinary action, including removal.

EMPLOYEE SIGNATURE

DATE

(mm/dd/yyyy)

8. OFFICIAL ACTION ON REQUEST:

APPROVED

DISAPPROVED

(If disapproved, give reason. If annual leave, initiate action to reschedule.)

SIGNATURE

DATE

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 to the General

Services Administration in connection with its responsibilities for records management.

Where the employee identification number is your Social Security Number, collection of this information is authorized by Executive Order 9397. Furnishing the information on this

form, including your Social Security Number, is voluntary, but failure to do so may result in disapproval of this request.

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.

NSN 7540-00-753-5067

STANDARD FORM 71 (Rev. 12-97)

PREVIOUS EDITION MAY BE USED

PRESCRIBED BY OFFICE OF PERSONNEL MANAGEMENT, 5 CFR PART 630