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The Employee Leave Request form is a critical tool for employees seeking to formally request time away from work for various reasons. It captures essential information including the employee's name, organization, and the last four digits of their Social Security Number to ensure proper identification and processing. The form outlines different types of leave, such as family and medical leave, sick leave, or leave without pay. Employees must specify the dates and hours they plan to be absent, providing details that help management understand the request's context. It is vital to check applicable leave options, such as accrued annual leave or sick leave, while also noting the reasons for the request, ranging from personal illness to family emergencies. Employees are reminded to consult with their supervisor or personnel office for guidance on procedures and any required documentation, including medical certification. This form also emphasizes the importance of accuracy, as providing false information may lead to disciplinary actions. After submission, the request will be reviewed and can either be approved or disapproved, with necessary comments provided by a supervisor. Lastly, the form includes a privacy act statement that outlines how the information will be used and shared, ensuring transparency in the process of leave management.

Form Sample

Request for Leave or Approved Absence

1.Name (Last, first, middle)

2.Employee or Social Security Number (Enter only the last 4 digits of the Social Security Number (SSN))

3.Organization

4. Type of Leave/Absence

 

Date

 

 

Time

Total

5. Family and Medical

(Check appropriate box(es) below)

From

 

To

 

From

 

To

Hours

Leave

 

 

Accrued Annual Leave

 

 

 

 

 

 

 

 

If annual leave, sick leave, or

 

 

 

 

 

 

 

 

 

 

 

 

leave without pay will be used

 

 

Restored Annual Leave

 

 

 

 

 

 

 

 

under the Family and Medical

 

 

 

 

 

 

 

 

 

 

 

 

Leave Act of 1993, please provide

 

 

Advanced Annual Leave

 

 

 

 

 

 

 

 

the following information:

 

 

 

 

 

 

 

 

 

 

 

 

I hereby invoke my

 

 

Accrued Sick Leave

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

entitlement to Family

 

 

Advanced Sick Leave

 

 

 

 

 

 

 

 

and Medical Leave for:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Birth/Adoption/Foster Care

 

 

 

 

 

 

 

 

 

 

 

 

Purpose:

Illness/injury/incapacitation of requesting employee

 

 

 

 

 

 

 

 

Serious health condition of

 

 

 

 

 

 

 

 

 

 

 

 

Medical/dental/optical examination of requesting employee

 

 

 

spouse, son, daughter, or

 

 

 

 

 

 

parent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Care of family member, including medical/dental/optical examination of family

 

Serious health condition of

 

 

 

member, or bereavement

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

self

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Care of family member with a serious health condition

 

 

 

 

Contact your supervisor and/or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

your personnel office to obtain

 

 

 

 

 

 

 

 

 

 

 

 

additional information about your

 

 

Compensatory Time Off

 

 

 

 

 

 

 

 

entitlements and responsibilities

 

 

 

 

 

 

 

 

 

 

 

 

under the Family and Medical

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Paid Absence

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Leave Act. Medical certification of

 

 

(Specify in Remarks)

 

 

 

 

 

 

 

 

a serious health condition may be

 

 

 

 

 

 

 

 

 

 

 

 

required by your agency.

 

 

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

7b. Date

8a. Official Action on Request:

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

Local Reproduction Authorized

5 CFR 630

 

 

 

 

 

Print Form

 

 

Save Form

 

 

 

 

 

 

 

Clear Form

OPM Form 71

Rev. September 2009

Formerly Standard Form (SF) 71

Previous editions usable

Document Specifications

Fact Name Details
Purpose of the Form This form is used to request leave or an approved absence from work.
Employee Information It requires the employee's name and the last four digits of their Social Security Number.
Type of Leave Various types of leave can be requested, including annual leave, sick leave, and leave without pay.
Family and Medical Leave Act This form allows employees to request leave under the Family and Medical Leave Act of 1993.
Certification Requirement Certification may be required to verify the need for leave, particularly for a serious health condition.
Privacy Act Statement Section 6311 of Title 5, United States Code governs the collection and use of employee information on this form.
Signature Requirement The employee must sign and date the form, certifying the accuracy of the information provided.
Supervisor Approval The request must be approved or disapproved by the employee’s supervisor, requiring their signature.
Implications of Falsification Falsifying information on the form may lead to disciplinary action, potentially including removal from employment.

Steps to Filling Out Employee Leave Request

Filling out the Employee Leave Request form is a straightforward process, ensuring all necessary information is properly documented. After you submit the completed form to your supervisor, they will review your request and take necessary actions according to your agency’s policies.

  1. Personal Information: Enter your name in the format of Last, First, Middle.
  2. Employee Identification: Provide the last four digits of your Social Security Number (SSN) in the designated field.
  3. Organization: Fill in the name of your organization or department.
  4. Type of Leave/Absence: Specify the type of leave you are requesting and fill in the relevant dates and times. Calculate the total leave time requested.
  5. Leave Type: Check the appropriate box for Family and Medical Leave or select any other applicable options.
  6. If applicable, provide details: If using Family and Medical Leave, include the requested information regarding the purpose of your leave.
  7. Additional Information: Use the Remarks section to provide any additional relevant details regarding your leave request.
  8. Certification: Sign and date the form to certify that you understand the requirements associated with your leave request.
  9. Supervisor's Review: After submission, the supervisor will indicate approval or disapproval, along with their signature and date.

More About Employee Leave Request

What information is required on the Employee Leave Request form?

The Employee Leave Request form requires several key pieces of information. You will need to provide your name, the last four digits of your Social Security Number, your organization, and the type of leave you are requesting. Additionally, dates, times, and total hours of the leave must be included. If applicable, specify whether you are using annual leave, sick leave, or leave without pay, and mark the relevant checkboxes for family and medical leave purposes.

How do I know if I am eligible for Family and Medical Leave?

Eligibility for Family and Medical Leave generally requires that you have worked for your employer for at least 12 months and have accumulated a minimum of 1,250 hours of service over the past year. Furthermore, your employer must be covered by the Family and Medical Leave Act, which typically includes federal, state, and local government agencies as well as private sector employers with 50 or more employees within a 75-mile radius.

What should I do if my leave request is disapproved?

If your leave request is disapproved, your supervisor must provide a reason for the denial on the form. It is advisable to have a discussion with your supervisor to understand their concerns and whether there are any options to reschedule or modify your leave request in light of the feedback provided.

Is medical certification always required for leave?

Medical certification may be required for certain types of leave, especially under family and medical leave provisions. Your agency will notify you if this is necessary. It's important to refer to your agency's guidelines for specific documentation requirements pertaining to your leave request.

What actions are required from my supervisor regarding the leave request?

Your supervisor must review the submitted Employee Leave Request form and either approve or disapprove it. If the request is approved, they will sign and date the form, confirming their action. In cases of disapproval, your supervisor should provide a clear reason which can aid your understanding and further discussions.

What are my responsibilities when requesting leave?

You are responsible for complying with your employing agency’s specific procedures when requesting leave. This may include submitting the form by a certain deadline, providing required documentation such as medical certification, and informing your supervisor as early as possible about your leave needs. Remember, providing false information on the form can lead to serious disciplinary action.

What happens to my personal information submitted on this form?

Your personal information is primarily used by management and payroll offices for scheduling leave. The Privacy Act provides guidelines regarding the use of your data, which may also be shared with various agencies for purposes such as processing compensation claims or conducting investigations. Always know that the provision of your Social Security Number is voluntary, but omitting it could slow down the processing of your application.

Can I edit or withdraw my leave request after submitting it?

Once submitted, the ability to edit or withdraw your leave request depends on your agency's policies. If changes are needed, it is best to discuss them directly with your supervisor as soon as possible. Communication practice will help in ensuring your needs are understood and met accordingly.

Common mistakes

  1. Neglecting to provide accurate personal information, such as incorrectly spelling the name or entering the wrong Social Security Number (only the last four digits).

  2. Failure to specify the type of leave being requested, such as annual leave, sick leave, or another absence. This information is crucial for processing the request.

  3. Not indicating the dates and times for the leave. Accurate periods of absence must be clearly outlined to avoid misunderstandings.

  4. Overlooking the need for medical certification when required for certain types of leave, especially in cases related to serious health conditions.

  5. Failing to read and understand the certification statement at the bottom of the form. This includes acknowledging the responsibilities involved and potential consequences of false information.

  6. Not signing or dating the form before submission. This step is essential for validating the request and confirming the information provided.

Documents used along the form

When submitting an Employee Leave Request, several other forms and documents may also be required to facilitate the smooth processing of your leave. Each of these documents plays a vital role in ensuring that the leave is justly managed, and it’s essential to understand their purposes.

  • Medical Certification Form: This document may be required if the leave request is based on health reasons. It typically confirms that an employee has a serious health condition and provides information on the expected duration of leave.
  • Family and Medical Leave Act (FMLA) Notice: This notice informs employees of their eligibility and rights under the FMLA. It outlines the process for taking leave for qualifying family and medical reasons.
  • Return-to-Work Form: This form is often needed after an employee returns from leave. It may require a healthcare provider’s confirmation that the employee is fit to resume work duties.
  • Leave of Absence Agreement: A formal agreement detailing the terms and duration of an employee’s leave. This document protects both the employee's and employer’s rights during the absence.
  • Vacation Request Form: If annual leave is being requested, this form may serve as a formal request to take vacation time. It usually outlines the specific dates the employee wishes to be off.
  • Sick Leave Request Form: Similar to the vacation request, this form specifically addresses the need for sick leave. It typically includes details about the sickness and expected return dates.
  • Bereavement Leave Request Form: When an employee needs time off due to a family loss, this form allows them to formally request bereavement leave, often detailing the relationship to the deceased.
  • Leave Donation Form: In cases where employees may donate their accrued leave to a colleague in need, this form facilitates that process and details how much leave is being donated.
  • Administrative Leave Form: For cases where the leave is granted for administrative reasons, this form allows the manager to document the reasons for and duration of the leave.

It’s crucial to review your company’s specific policies regarding leave, as the requirements for documentation may vary. Understanding these forms can help in preparing a complete and effective leave request, ensuring compliance with workplace policies.

Similar forms

The Sick Leave Request form bears similarities to the Employee Leave Request form. Both documents require employees to indicate the specific dates and type of leave being requested. They emphasize the importance of providing a reason for the leave. Employees using the Sick Leave Request form typically must also affirm that the leave is necessary due to illness, injury, or medical appointments, mirroring the requirements for family and medical reasons present in the Employee Leave Request form.

The Vacation Request form is another document comparable to the Employee Leave Request form. Both forms ask for essential employee information, such as name and contact details. When requesting vacation time, employees also specify the duration of the leave. The Vacation Request form requires that the employee's request be planned in advance, similar to the structure within the Employee Leave Request, which necessitates notification to the supervisor for approval.

The Personal Leave Request form also shows a strong resemblance to the Employee Leave Request form. Like the Employee Leave Request, this form captures basic employee details and allows the submission of various leave reasons. Both documents generally require signatures affirming the request's authenticity, and supervisors must review and approve or deny the request based on company policies.

The Bereavement Leave Request form shares key characteristics with the Employee Leave Request form by focusing on specific types of leave. Employees submitting this form usually provide the dates of absence and the relationship of the deceased, which parallels the need for family-related reasons outlined in the Employee Leave Request. Both documents facilitate the communication of critical leave reasons between employees and management.

The Family Leave Request form is comparable to the Employee Leave Request form, particularly regarding the need for medical certification. When requesting family leave, employees typically must provide documentation substantiating their need for the leave. Similarly, the Employee Leave Request indicates the potential need for medical certification for serious health conditions, ensuring that both leave types are supported by adequate justification.

Lastly, the Time Off Request form reflects many features found in the Employee Leave Request form. Employees fill out essential personal information and specify the amount of time off they desire, along with the reason. In both instances, employer approval is essential. Both forms highlight the importance of adhering to company policies regarding scheduled time off, ensuring that all requests are managed effectively and transparently.

Dos and Don'ts

When filling out the Employee Leave Request form, adhering to best practices can ensure a smooth process. Here are ten important do's and don'ts to consider:

  • Do: Clearly write your name as it appears on your records. Accuracy matters.
  • Do: Include only the last four digits of your Social Security Number to protect your privacy.
  • Do: Specify the type of leave you are requesting. Make sure to check the appropriate boxes.
  • Do: Mention the exact dates and times for your leave to avoid confusion.
  • Do: Review the policy on leave entitlements and requirements before submitting the form.
  • Don’t: Leave any section blank unless it is labeled as optional; incomplete forms may cause delays.
  • Don’t: Falsify any information on the form; disciplinary actions can result from false statements.
  • Don’t: Forget to sign and date the form where indicated; unsigned requests may be rejected.
  • Don’t: Ignore instructions for additional documentation; failing to provide required documents can lead to disapproval.
  • Don’t: Submit the form without checking for errors; a quick review can prevent issues.

Remember, following these guidelines will facilitate the processing of your leave request and help maintain a good relationship with your employer.

Misconceptions

Misconceptions about the Employee Leave Request form can lead to confusion and frustration among employees. Below is a list of six common misconceptions along with clarifications.

  • 1. Submitting the form guarantees leave approval.

    Submitting the request does not automatically mean that the leave will be approved. Supervisors review requests based on agency policies and operational needs.

  • 2. Only medical leave is covered by this form.

    The form accommodates various types of leave, including annual leave, sick leave, bereavement leave, and leave without pay, among others.

  • 3. Only full-time employees can request leave.

    Part-time employees also have the right to request leave as long as they follow the same procedures outlined in the form.

  • 4. Medical certification is always required.

    Medical certification may be required in certain situations, particularly for serious health conditions, but is not necessary for all types of leave requests.

  • 5. The form does not require a reason for leave.

    Employees must specify a reason for their leave request. This helps management better understand the nature of the absence and make informed decisions.

  • 6. Falsifying information on the form has no consequences.

    Providing false information can lead to disciplinary action, including termination. The form explicitly states the importance of honesty in the application process.

Key takeaways

When filling out and using the Employee Leave Request form, keep these six key takeaways in mind:

  • Accurate Information: Ensure all sections of the form are filled out completely and accurately to avoid delays in processing your leave request.
  • Type of Leave: Clearly indicate the type of leave you are requesting. Options include annual leave, sick leave, or leave without pay.
  • Medical Certification: Be aware that some leaves may require medical certification, particularly for serious health conditions. Check with your supervisor or HR if unsure.
  • Signature Requirement: Your signature is mandatory. By signing, you acknowledge your understanding of the agency’s procedures and repercussions for falsifying information.
  • Supervisor's Action: The supervisor will approve or disapprove your request. If declined, they must provide a reason and, if applicable, assist with rescheduling.
  • Privacy Considerations: Understand that the information collected on this form may be shared with various agencies as needed for compliance and processing of your leave.