Request for or Notification of Absence - Postal

1 Request for or Notification of AbsenceEmployee's Name (Last, First, )YearDate SubmittedSocial Security of Hours RequestedInstallation (For PM leave, show city, state, and ZIP code)N/S DayFrom DateHourD/A CodePay Loc. #Time of Call or RequestThru DateHourEmployee Can Be Reached At (if needed)Scheduled Reporting TimeNo CallType of AbsenceDocumentation (For official use only)Revised Schedule for (Date)Approved in AdvanceYesAnnualNoFor FMLA Leave (Certification reviewed)Carrier 701 RuleFor COP Leave (CA 1 on file)LWOP (See reverse)For Advanced Sick Leave (1221 on file)Sick (See reverse)For Military Leave (Orders reviewed)LateFor Court Leave (Summons reviewed)COPFor Higher Level (I 723 on Me)Other.

2 Scheme Training Testing, Qualifying (Memo on file)Remarks (Do not enter medical information)I understand that the annual leave authorized in excess of amount available to me during the leave year will be changed to 's Signature and DateSignature of Supervisor and Date NotifiedSignature of Person Recording Absence and DateticSignature of Supervisor and DateApproved, not FMLA*Approved, FMLAA pproved FMLA, PendingDocumentation Noted on Reverse.(See Publication 71)Disapproved (Give reason):Ineligible for FMLA (Estimate eligibility date):Continued on ReversePS Form 3971, April 2001 (Page I of 2)Warning. The furnishing of false information on this form may result in a fine of not morethan $1 0,000 or imprisonment of not more than 5 years, or both.

3 (18 1001)--UN-During This Absence , I Was Incapacitated for Duty Medical, Dental, orOptical Examination or Treatment(Job related)On-the-Job InjuryAL-FMLA55/0132 Off-the-Job injurySL-FMLA56/0233 Undergoing Medical, Dental, orLWOP - FMLA - Part DayLWOP - FMLA - Full DayLWOP Lieu of Sick Leave59/0536 Pregnancy and ConfinementOptical Examination or Treatment(Not job related)3760/06 Exposed to a Contagious Disease59/6020-LWOP Proffered2159/60 During This Absence , I Was Unavailable for Duty Because-,-22 LWOP Personal Reasons59/60-Sick Leave for Dependent CarePlacement of a Child with EmployeeLWOP Part Day5923-for Adoption or Foster CareLWOP Full DayBirth of Child - Bonding6023-LWOP AWOL59/6024 Additional Information Regarding Denial of Leave Protection Under FMLA.

4 -49 LWOP IOD (Not FMLA) - OWCPLWOP MaternityLWOP SuspensionLWOP Union OfficialLWOP Suspension Pending25-Employee Not Eligible - Less than 1250 Hours Not Eligible -- Not Employed with USPS 1 Year59/6027-8428-Employee Has Exhausted FMLA Entitlement in Current Leave Not for a Covered of Pay USPSA bsence Not for a Covered Family of Pay USPS-FMLA 71/03-Requested Documentation Not Provided,35 Continuation of Pay FMLA-IOD-OWCP 49/04 Documentation Provided. Does Not Meet Criteria for FMLA Duty04 Additional Documentation Required67 Military 's OrganizationBlood Donor Leave6909 Other Paid Leave1086 Convention Leave6612 Acts of God7813 Veteran's Funeral1086 Privacy Act: The collection of this information is authorized by 39 USC 401.

5 1001, 1003. 1005; 5 JSC 8339; and Public Law 103-3. This information will be used to grant or deny your Request forofficial leave from Postal Service duty. It may be disclosed under the routine uses given in PrivacyAct system notices USPS and USPS (see appendix of Administrative SupportManual or, if you wish to obtain a copy of these notices contact your personnel office). Completionof this form is voluntary. If this information is not provided. Official leave may not be Defense7716 Civil Disorder17818518 Voting LeavePS Form 3971, April 2001 (Page 2 of 2)UN-Official Action on Application (Return copy of signed Request to employee) WorkLunch-OutLunch-inEnd WorkTotal HoursSat01 Sun02 Mon03 Tue04 Wed05 Thur06 Fri07 Sat08 Sun09 Mon10 Tue1 1 Wed12 Thur13 Fri14 Leave Types (Information Only)Time CardPSDSL eave 1 Wed12 Thur13F d14