Ps Form 5980 - Treatment Verification For Wounded Warriors Leave

Treatment Verification for Wounded Warriors Leave

A. Employee Information (To be completed by the employee)

Name (Last, First, Middle Initial)

Employee ID

Date Submitted

Installation

Date of Appointment with

Time of Appointment with

Health Care Provider

I certify that I am requesting Wounded Warriors Leave in conjunction with a military service-connected disability rated at 30 percent

or more. I have provided documentation to the Postal Service from the Department of Veterans Affairs, or on any Office of Personnel

Management (OPM) certification form developed for administration of Wounded Warriors Leave, certifying that I have a qualifying

service-connected disability, as required in Management Instruction EL-510-2016-8.

I also acknowledge that I have 15 calendar days from the date I return to work to provide this verification to the appropriate

supervisor to use Wounded Warriors Leave in lieu of sick leave, annual leave, or leave without pay.

Employee Signature

Date

Privacy Act Statement: Your information will be used to administer leave. Collection is authorized by 39 USC 401, 404, 1001, 1003, and 1005; and 29

USC 2601 et seq. Providing the information is voluntary, but if not provided, we may not process your request. Your information may be disclosed as follows:

in relevant legal proceedings; to law enforcement when the USPS or requesting agency becomes aware of a violation of law; to a congressional office at

your request; to entities under contract with USPS and/or authorized to perform audits; to labor organizations as required by law; to government agencies

regarding personnel matters; to the EEOC; and to the MSPB or Office of Special Counsel. For more information regarding our privacy policies visit

com/privacypolicy.

B. Provider Information (To be completed by the health care provider)

Name of Physician/Provider

Specialty

Name of Health Care Facility

Contact Telephone Number

Please provide details of any treatment required, including the frequency and/or duration of any course of action you may prescribe,

that would necessitate the employee taking additional leave from work beyond the date of appointment identified in the Employee

Information portion of this verification form.

The above-referenced employee is requesting to take leave under the Wounded Warriors Federal Leave Act of 2015 for treatment of

a service-connected disability, as certified by the U.S. Department of Veterans Affairs. Treatment is defined as an in-person visit to a

health care provider and includes the course of action prescribed by a health care provider. Your signature below, as the health care

provider, verifies that the identified employee is undergoing treatment for a certified disabling condition.

Health Care Provider Signature

Date

Printed Name

C. Official Action on Application (Return copy of signed request to employee)

Approved

Disapproved

Reason/Reason Code for disapproval (if applicable):

Supervisor Signature

Date

PS Form 5980, December 2016

Ps Form 5980 - Treatment Verification For Wounded Warriors Leave - Usps Form

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