Request For Leave And Approved Absence
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11. NAME
2. EMPLOYEE OR SOCIAL SECURITY NUMBER
(Last, First, Middle Initial)
3. ORGANIZATION
4. TYPE OF LEAVE/ABSENCE
DATE
TIME
TOTAL
5. FAMILY AND MEDICAL
(Check appropriate box(es) below.)
HOURS
LEAVE
From:
To:
From:
To:
Accrued Annual Leave
If annual leave, sick leave, or leave without
pay will be used under the Family and Medical
leave Act of 1993, please provide the
Restored Annual Leave
following information:
Advanced Annual Leave
I hereby invoke my entitlement to Family
and Medical Leave for:
Accrued Sick Leave
Birth/Adoption/Foster Care
Advanced Sick Leave
Serious Health Condition of Spouse, Son,
Daughter, or Parent
Purpose:
Medical/dental/optical examination of requesting employee
Other
Serious Health Condition of Self
Care of family member/bereavement, including medical/dental/optical
examination of family member
Contact your supervisor and/or your personnel office to
Compensatory Time Off
obtain additional information about your entitlements
and responsibilities under the Family and Medical
Leave Act of 1993.
Other Paid Absence
(Specify in Remarks)
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 comly with my employing agency's procedures for requesting leave/approved absence (and provide
additional documentation, including medical certification, if required) and that falisfication of information on this form may be grounds for disciplinary
action, including removal.
EMPLOYEE SIGNATURE
DATE
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 ciminal 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.
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.
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