Transcription of Request for or Notification of Absence
1 Request for or Notification of AbsenceNo. of Hours RequestedFrom DateThru DateHourHourRevised Schedule for (Date)Approved in AdvanceYesNoBegin WorkLunch-OutLunch-InEnd WorkTotal HoursOfficial Action on Application (Return copy of signed Request to employee)Signature of Supervisor and DatePS Form 3971, March 2008 (Page 1 of 2)PSN 7530-02-000-9136 Pay Loc. #D/A CodeN/S DayDate SubmittedEmployee's Name (Last, First, )Installation (For PM leave, show city, state, and ZIP code)Time of Call or RequestScheduled Reporting Time Employee Can Be Reached At (If needed)No CallType of AbsenceDocumentation (For official use only)AnnualLWOP (See reverse)Other: Carrier 701 RuleRemarks (Do not enter medical information)For COP Leave (CA1 on file)For Advanced Sick Leave (1221 on file)For Military Leave (Orders reviewed)For Court Leave (Summons reviewed)For Higher Level (1723 on file)Scheme Training Testing, Qualifying (Memo on file)Employee's Signature and DateSignature of Supervisor and Date NotifiedSignature of Person Recording Absence and DateI understand that the annual leave authorized in excess of amount available to me during the leave year will be changed to :The furnishing of false information on this form may result in a fine of not more than $10,000 or imprisonment of not more than 5 years, or both.
2 (18 1001)Approved, not FMLAD isapproved (Give reason): Approved, FMLA(See Publication 71)PP YearDay Init. HoursScheduledUn-ScheduledSat01 Sun02 Mon03 Tue04 Wed05 Thur06 Fri07 Sat08 Sun09 Mon10 Tue11 Wed12 Thur13 Fri14 For FMLA Leave (Certification reviewed)COPLateSick (See reverse)Holiday/AL Lv ExchEmployee IDApproved FMLA, Pending Documentation Noted on on ReverseIneligible for FMLA (Estimate eligibility date): PS Form 3971, March 2008 (Page 2 of 2)Leave Types (Information Only)CODEST imecardTime ClockLeave TypeAnnual FMLASick FMLASick - Dependent CareAbsent Without LeaveAct of GodBlood DonorCivil DefenseCivil DisorderCOP - USPSCOP - USPS - FMLAC onventionCourt DutyDonated - FMLAHQ Authorized AdministrativeHoliday/AL Leave ExchangeLWOP - Part DayLWOP - Full DayLWOP - FMLA - Part DayLWOP - FMLA - Full DayLWOP - IOD/OWCP-- FMLALWOP - IOD/OWCP - not FMLALWOP - Lieu of Sick LeaveLWOP - MaternityLWOP - MilitaryLWOP - Personal ReasonsLWOP - ProfferedLWOP - SuspensionLWOP - Suspension Pend.
3 Tem. LWOP - Union OfficialMilitaryRelocationVeteran s FuneralVoting LeaveOther Paid555656247869778171716661467928596059 60494959 or 6059 or 604459 or 6059 or 6059 or 6059 or 6084678086858601020703050604055990569905 6970240007800069000770008100071000719906 6000610004600079000280005900060000599906 099049990490005901 or 0600105905 or 060050440005903 or 0600305902 or 0600205906 or 0600605908 or 06008084000670008000086000850008600 Employee: Reason I Was Incapacitated for Duty During this AbsenceAdditional Documentation RequiredSicknessOn-the-Job InjuryOff-the-Job InjuryPregnancy and ConfinementExposed to a Contagious DiseaseUndergoing Medical, Dental, orOptical Examination or Treatment(Job related)PP YearDay Init. HoursScheduledUn-ScheduledSat01 Sun02 Mon03 Tue04 Wed05 Thur06 Fri07 Sat08 Sun09 Mon10 Tue11 Wed12 Thur13 Fri14 Undergoing Medical, Dental, orOptical Examination or Treatment(Not job related)Sick Leave for Dependent CarePlacement of a Child with Employeefor Adoption or Foster CareSupervisor:Additional Documentation Regarding Denial of Leave ProtectionUnder FMLAE mployee Not Eligible -- Less than 1250 Hours Not Eligible -- Not Employed with USPS 1 Has Exhausted FMLA Entitlement in Current Leave Not for a Covered Documentation Not Not for a Covered Family Provided.
4 Does Not Meet Criteria for FMLA I Was Unavailable for Duty During This AbsenceBirth of Child - BondingPrivacy Act Statement:Your information will be used to administer is authorized by 39 USC 401, 404, 1001, 1003, and 1005; and 29 USC2601 et seq. Providing the information is voluntary, but if not provided, we maynot process your Request . Your information may be disclosed as follows: inrelevant legal proceedings; to law enforcement when the USPS or requestingagency becomes aware of a violation of law; to a congressional office at yourrequest; to entities under contract with USPS and/or authorized to perform audits;to labor organizations as required by law; to government agencies regardingpersonnel matters; and to the EEOC; MSPB or Office of Special Counsel.
