REQUEST FOR LEAVE OR APPROVED ABSENCE

REQUEST FOR LEAVE OR APPROVED ABSENCE
NAME:

First NameMiddle InitialLast Name
EMPLOYEE OR SOCIAL SECURITY NUMBER
ORGANIZATION
COMPANY NAME
TYPE OF LEAVE/ABSENCE (Check appropriate box(es) below.)

Accrued Annual LeaveRestored Annual LeaveAdvance Annual LeaveAccrued Sick LeaveAdvance Sick Leave
Purpose:

Medical/dental/optical examination of requesting employeeCare of family member/bereavement, including medical/dental/optical examination of family memberOther

Date:

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1
2
3
4
5

Time:

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1
2
3
4
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:
I hereby invoke my to Family and Medical Leave for:Birth/Adoption/Foster CareSerious Health Condition ofSpouse, Son, Daughter, or ParentSerious Health Condition of Self
Contact your supervisor and/or your personnel office to obtain additional information about our entitlements and responsibilities under the Family and
Medical Leave Act of 1993.

Rows	Check	1	2	3	4
Compensatory Time Off
Other Paid Absence
Leave Without Pay

REMARKS:
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.
EMPLOYEE SIGNATURE

Clear
Date

MonthDayYear
Date
OFFICIAL ACTION ON REQUEST:

APPROVEDDISAPPROVED
(If disapproved, give reason. If annual leave, initiate action to reschedule.)
SIGNATURE

Clear
Date

MonthDayYear
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 to 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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