Equal Employment Opportunity (Eeo) Policy And Program Administration Form Sample Page 36
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54ATTACHMENT 1
REQUEST FOR LEAVE OR APPROVED ABSENCE
1. Name (Last, First, Middle Initial)
2
. EMPLOYEE OR SOCIAL SECURITY NUMBER
3. Organization
4.
5. FAMILY AND MEDICAL LEAVE
Type of Leave/Absence
If annual leave, sick leave, or leave without pay will
Check appropriate box(es) below and
Date
Time
Total
be used under the Family and Medical Leave Act
enter date and time below
Hours
:
(FLMA, please provide the following information
From
To
From
To
Accrued Annual Leave
I hereby invoke my entitlement to
Family and Medical Leave for:
Restored Annual Leave
Birth/Adoption/Foster Care
Serious Health Condition of Spouse,
Advance Annual Leave
Son, Daughter, or Parent
Serious Health Condition of Self
Accrued Sick Leave
.
Contact your supervisor and/or your
Advance Sick Leave
personnel office to obtain additional
information about your entitlements and
Purpose:
Illness/injury/incapacitation of requesting employee
responsibilities under the FMLA. Medical
certification of a serious health condition
Medical/dental/optical examination of requesting employee
may be required by your agency
Care of family member/bereavement, including medical/dental/optical examination of
family member, or bereavement
Care of family member with a serious health condition
Other
Compensatory Time Off
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 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.
7a. Employee signature
7b. Date signed
(If disapproved, give reason. If annual leave,
8a. Official action on request
Approved
Disapproved
initiate action to reschedule.)
8b. Reason for disapproval
8c.. Signature
8d. Date signed
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