Request for Leave or Approved Absence 2. Employee or Social Security Number (Enter only the last 4 digits of the Social Security Number (SSN)) 1. Name (Last, first, middle) 3. Organization (Check appropriate box(es) below) Time Date 4. Type of Leave/Absence From To From To Total Hours 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, please provide the following information: Accrued Annual Leave Restored Annual Leave Advanced Annual Leave I hereby invoke my entitlement to Family and Medical Leave for: Accrued Sick Leave Advanced Sick Leave Birth/Adoption/Foster Care Purpose: Illness/injury/incapacitation of requesting employee Medical/dental/optical examination of requesting employee Serious health condition of spouse, son, daughter, or parent Care of family member, including medical/dental/optical examination of family member, or bereavement Serious health condition of self Care of family member with a serious health condition Contact your supervisor and/or your personnel office to obtain additional information about your entitlements and responsibilities under the Family and Medical Leave Act. Medical certification of a serious health condition may be required by your agency. 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 on this form may be grounds for disciplinary action, including removal. 7a. Employee Signature 8a. Official Action on Request: 7b. Date Approved Disapproved (If disapproved, give reason. If annual leave, initiate action to reschedule.) 8b. Reason for Disapproval: 8c. Supervisor Signature 8d. 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 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 furnished on 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 Local Reproduction Authorized OPM Form 71 Rev. September 2009 Formerly Standard Form (SF) 71 Previous editions usable American LegalNet, Inc. www.FormsWorkFlow.com