Request for Leave or Approved Absence 1. Name (Last, first, middle) 2. Employee or Social Security Number 3. Organization 4. Type of Leave/Absence ___Accrued annual leave Date______ From______ To______ Time_______ From______ To______ Total Hours_____ ___Restored annual leave Date______ From______ To______ Time_______ From______ To______ Total Hours_____ ___Advance annual leave Date______ From______ To______ Time_______ From______ To______ Total Hours_____ ___Accrued sick leave Date______ From______ To______ Time_______ From______ To______ Total Hours_____ ___Advance sick leave Date______ From______ To______ Time_______ From______ To______ Total Hours_____ Purpose: ___Illness/injury/incapacitation of requesting employee ___Medical/dental/optical examination of requesting employee ___Care of family member, 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 5. Family and Medical Leave If annual leave, sick leave, or leave without pay will be used under the Family and Medical Leave Act of 1993 (FMLA), please provide the following information: ___I hereby invoke my entitlement to family and medical leave for: ___Birth/Adoption/Foster care ___Serious health condition of spouse, son, daughter, or parent ___Serious health condition of self Contact your supervisor and/or your personnel office to obtain additional information about your entitlements and responsibilities under the FMLA. Medical certification of a serious health condition may be required by your agency. 6. Remarks: ________________________________________________________________________________________ ________________________________________________________________________________________ 7. Certification: I certify that the leave/absence requested above is 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___________________ 8a. Official action on request ___Approved ___Disapproved (If disapproved, give reason. If annual leave, initiate action to reschedule.) 8b. Reason for disapproval___________________________________________________________________ 8c. Signature__________________________ 8d. Date signed_______________________ 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 the General Services Administration in connection with its responsibilities for records management. Public Law 104-134 (April 26, 1996) requires that any person doing business with the Federal Government furnish a social security number or tax identification number. This is an amendment to title 31, Section 7701. Furnishing the social security number, as well as other data, is voluntary, but failure to do so may delay or prevent action on the application. If your agency uses the information furnishedon this form for purposes other than those indicated above, it may provide you with an additional statement reflecting those purposes. Office of Personnel Management 5 CFR 630 OPM Form 71 June 2001 Formerly Standard Form (SF) 71 Local Reproduction Authorized