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Sample Leave Form

This document is a request for leave or approved absence form containing the following key information: 1. It requests information about the employee such as name, social security number, and organization. 2. It specifies the type of leave being requested such as annual leave, sick leave, family medical leave, or leave without pay along with the dates and total hours. 3. For family medical leave, it requires additional information about the purpose and certification that may be required. 4. Space is provided for remarks and the employee and supervisor signatures to approve or disapprove the request along with a reason for disapproval.

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Bobec Tungol
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340 views1 page

Sample Leave Form

This document is a request for leave or approved absence form containing the following key information: 1. It requests information about the employee such as name, social security number, and organization. 2. It specifies the type of leave being requested such as annual leave, sick leave, family medical leave, or leave without pay along with the dates and total hours. 3. For family medical leave, it requires additional information about the purpose and certification that may be required. 4. Space is provided for remarks and the employee and supervisor signatures to approve or disapprove the request along with a reason for disapproval.

Uploaded by

Bobec Tungol
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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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

Serious health condition of


spouse, son, daughter, or
parent

Medical/dental/optical examination of requesting employee


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

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