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(Last,first,middle)   |  |  |  | 2.Employee or Social Security Number(Enter only the  \u003Cbr>last 4 digits of the Social Security Number(SSN))   |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n| 3.Organization   |  |  |  |  |  |  |  |\n| 4.Type of Leave/Absence  \u003Cbr>(Check appropriate box(es)below)   | Date  \u003Cbr>To  \u003Cbr>From   |  | Time  \u003Cbr>To  \u003Cbr>From   |  |  | Total  \u003Cbr>Hours   | 5.Family and Medical  \u003Cbr>Leave   |\n| □Accrued Annual Leave  \u003Cbr>□Restored Annual Leave  \u003Cbr>□Advanced Annual Leave   |  |  |  |  |  |  | If annual leave,sick leave,or  \u003Cbr>leave without pay will be used  \u003Cbr>under the Family and Medical  \u003Cbr>Leave Act of 1993,please provide  \u003Cbr>the following information:  \u003Cbr>I hereby invoke my  \u003Cbr>□entitlement to Family  \u003Cbr>and Medical Leave for:  \u003Cbr>□Birth/Adoption/Foster Care  \u003Cbr>Serious health condition of  \u003Cbr>□spouse,son,daughter,or  \u003Cbr>parent  \u003Cbr>□Serious health condition of  \u003Cbr>self  \u003Cbr>Contact your supervisor and/or  \u003Cbr>your personnel office to obtain  \u003Cbr>additional information about your  \u003Cbr>entitlements and responsibilities  \u003Cbr>under the Family and Medical  \u003Cbr>Leave Act.Medical certification of  \u003Cbr>a serious health condition may be  \u003Cbr>required by your agency.   |\n|  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n| □Accrued Sick Leave  \u003Cbr>□Advanced Sick Leave   |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n| Purpose:□Ilness/injury/incapacitation of requesting employee  \u003Cbr>□Medical/dental/optical examination of requesting employee  \u003Cbr>□Care of family member,including medical/dental/optical examination of family  \u003Cbr>member,or bereavement  \u003Cbr>□Care of family member with a serious health condition  \u003Cbr>□Other   |  |  |  |  |  |  |  |\n| □Compensatory Time Off   |  |  |  |  |  |  |  |\n| Other Paid Absence  \u003Cbr>(Specify in Remarks)   |  |  |  |  |  |  |  |\n| □Leave Without Pay   |  |  |  |  |  |  |  |\n| 6.Remarks:   |  |  |  |  |  |  |  |\n| 7.Certification:I hereby request leave/approved absence from duty as indicated above and certify that such leave/absence is  \u003Cbr>requested for the purpose(s)indicated.I understand that I must comply with my employing agency's procedures for requesting leave/  \u003Cbr>approved absence(and provide additional documentation,including medical certification,if required)and that falsification on this form may  \u003Cbr>be grounds for disciplinary action,including removal.   |  |  |  |  |  |  |  |\n| 7a.Employee Signature   |  |  |  |  |  | 7b.Date   |  |\n| (If disapproved,give reason.If annual leave,  \u003Cbr>□Disapproved  \u003Cbr>□Approved  \u003Cbr>8a.Official Action on Request:  \u003Cbr>initiate action to reschedule.)   |  |  |  |  |  |  |  |\n| 8b.Reason for Disapproval:   |  |  |  |  |  |  |  |\n| 8c.Supervisor Signature   |  |  |  |  |  | 8d.Date   |  |\n| PRIVACY ACT STATEMENT  \u003Cbr>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  \u003Cbr>office to approve and record your use of leave.Additional disclosures of the infomation may be:to the Department of Labor when processing a claim for  \u003Cbr>compensation regarding a job connected injury or illness;to a State unemployment compensation office regarding a claim;to Federal Life Insurance or Health  \u003Cbr>Benefits carriers regarding a claim;to a Federal,State,or local law enforcement agency when your agency becomes aware of a violation or posible violation of  \u003Cbr>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  \u003Cbr>General Accounting Office when the information is required for evaluation of leave administration;or the General Services Administration in connection with its  \u003Cbr>responsibilities for records management.  \u003Cbr>Public Law 104-134(April 26,1996)requires that any person doing business with the Federal Government furnish a social security number or tax identifi","cbCaigznqn0qCvli","https://ap.wps.com/l/cbCaigznqn0qCvli","pdf",738541,"English","# Request for Leave or Approved Absence\n## Employee and Leave Details\n## Family and Medical Leave Information\n## Purpose and Remarks\n## Certification and Signatures\n## Official Action and Disapproval Reason\n## Privacy Act Statement","[{\"question\":\"What information is required to submit a leave request on this form?\",\"answer\":\"The form collects the employee’s name, employee or SSN last four digits, organization, leave type, dates and times (from/to), and total hours, along with any remarks if applicable.\"},{\"question\":\"How does the form handle Family and Medical Leave Act eligibility?\",\"answer\":\"If annual leave, sick leave, or leave without pay is used under the Family and Medical Leave Act of 1993, the employee must invoke eligibility and indicate the qualifying reason such as birth/adoption/foster care, a serious health condition of a spouse/child/parent, or the employee’s own serious health condition.\"},{\"question\":\"What are the consequences of providing false information on the form?\",\"answer\":\"The certification section states that falsification on the form may be grounds for disciplinary action, including removal.\"}]","Request for Leave or Approved Absence - OPM Form 71 | PDF"]