Fillable Ps Form 3971 - Request For Or Noti Cation Of Absence printable pdf download

Request for or Noti cation of Absence

Employee’s Name

Employee ID

Date Submitted

No. of Hours Requested

Year

(Print last, rst, MI.)

(MM/DD/YYYY)

Installation

N/S Day

Pay Loc. No. D/A Code

From: Date

Hour

(For postmaster’s leave, show city, state, and ZIP Code)

N/A

Time of Call or Request

Scheduled Reporting Time

If Needed, Employee Can Be Reached At:

Thru: Date

Hour

Day

Init.

Hours

Do not call

Type of Absence

Documentation

Revised Schedule for

Approved in Advance

(For of cial use only)

(Date)

Sat

Annual

FMLA Requested

Yes

(Certi cation review – HRSSC)

Holiday/AL Lv Exch

Sun

For COP Leave

Begin Work

(CA1 on le)

Carrier 701 Route

For Advanced Sick Leave

(PS 1221 on le)

Mon

LWOP

Lunch Out

Lunch In

(See reverse)

For Military Leave

(Orders reviewed)

Sick

(See reverse)

Tue

For Court Leave

(Summons reviewed)

End Work

Late

For Higher Level

COP

(PS 1723 on le)

(See reverse)

Wed

Total Hours

Other _____________________

Scheme Training Testing Qualifying

(Memo on le)

Thur

Remarks

(Do not enter medical information. See Privacy Act Statement on reverse of this form.)

Fri

Sat

I understand that the annual leave authorized in excess of the amount available to me during the leave year will be charged to LWOP.

Sun

Employee’s Signature and Date

Signature of Person Recording Absence and Date

Signature of Supervisor and Date Noti ed

Mon

Of cial Action on Application (Return copy of signed request to employee.)

Tue

Do not check an FMLA box until you verify the

Signature of Supervisor and Date

Approved

Wed

FMLA designation.

Disapproved (Give reason below)

FMLA Designation is PENDING

Thur

FMLA Protected

Continued on reverse

Fri

Not FMLA Protected

PS Form 3971, October 2017

Warning: The furnishing of false information on this form may result in a ne of not more

(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).

Reason I was incapacitated for duty during this absence:

Leave Types and Codes

Time

Time Clock

FMLA

Year

Card

Dep. Care

(Information Only)

Sickness

Pregnancy, Prenatal Care, or Childbirth

Annual

05500

On-the-Job Injury

Undergoing Medical, Dental, or Optical

Annual – FMLA

05599

Examination or Treatment (Job-related)

Off-the-Job Injury

Sick

05600

Undergoing Medical, Dental, or Optical

Sick – FMLA

05699

Exposed to a

Examination or Treatment

Contagious Disease

Sick – Dependent Care

05697

(Not job-related)

Sick – Dependent Care – FMLA

05698

Day

Init.

Hours

Reason I was/will be unavailable for duty during this absence:

Absent Without Leave

02400

Sick Leave for Dependent

Placement of a Child with Employee

Act of Nature

07800

Sat

Care (See ELM)

for Adoption or Foster Care

Blood Donor

06900

Civil Defense

07700

Sun

Birth of a Child/Bonding

A Military Family Member’s Qualifying

Civil Disorder

08100

Exigency

To Care for a Family

COP – USPS

07100

Mon

Member (See ELM)

To Care for an Injured or Ill Military

COP – USPS – FMLA

07199

Family Member

Court Duty

06100

Tue

LWOP - Union Of cial (Required Certi cation)

Donated

04500

Donated – FMLA

04600

By signing this form, I certify that this request is not for the purpose of engaging in

Wed

HQ Authorized Administrative

07900

partisan political activity as de ned by the Hatch Act and its implementing regulations.

Holiday – AL Leave Exchange

02800

Thur

I am requesting Family and Medical Leave Act (FMLA) protection

LWOP – Part Day

05900

for this absence:

LWOP – Part Day – FMLA

05999

Fri

This request is associated with a new condition. (You will receive

LWOP – Full Day

06000

an FMLA packet in the mail with forms and instructions.)

LWOP – Full Day – FMLA

06099

Sat

LWOP – IOD/OWCP

04900

My approved or pending approval case number for this condition is:

LWOP – IOD/OWCP – FMLA

04999

Sun

LWOP – In Lieu of Sick Leave

59 or 60

05901 or 06001

Employee must not be asked to disclose personal medical information to local

LWOP – Maternity

59 or 60

05905 or 06005

management. FMLA certi cation must be mailed to HRSSC.

Mon

LWOP – Military

04400

Additional Documentation Required as follows:

LWOP – Personal Reasons

59 or 60

05903 or 06003

Tue

LWOP – Proffered

59 or 60

05902 or 06002

LWOP – Suspension

59 or 60

05906 or 06006

Wed

Privacy Act Statement: Your information will be used to administer leave. Collection is authorized by

LWOP – Suspension Pend Term

59 or 60

05908 or 06008

39 USC 401, 404, 1001, 1003, and 1005; and 29 USC 2601 et seq. Providing the information is

LWOP – Union Of cial

08400

voluntary, but if not provided, we may not process your request. Your information may be disclosed as

Thur

Military

06700

follows: in relevant legal proceedings; to law enforcement when the USPS or requesting agency becomes

aware of a violation of law; to a congressional of ce at your request; to entities under contract with USPS

Relocation

08000

and/or authorized to perform audits; to labor organizations as required by law; to government agencies

Fri

Voting Leave

08500

regarding personnel matters; to the EEOC; and to the MSPB or Of ce of Special Counsel. For more

information regarding our privacy policies visit

Other Paid Leave

08600

PS Form 3971, October 2017

(Page 2 of 2) PSN 7530-02-000-9136

Ps Form 3971 - Request For Or Noti Cation Of Absence

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