Request for or Notification of Absence

1 Request for or Notification of Absence Scheduled scheduled Employee's Name (Last, First, ) Social Security No. Date Submitted No. of Hours Requested PP Year UN- Installation (For PM leave , show city, state, and ZIP code) N/S Day Pay Loc. # D/A Code From Date Hour Day Init. Hours Sat 01. Time of Call or Request Scheduled Reporting Time Employee Can Be Reached At (if needed) Thru Date Hour Sun No Call 02. Type of Absence Documentation (For official use only) Revised Schedule for (Date) Approved in Advance Mon 03. Annual For fmla leave (Certification reviewed) Yes No Tue Carrier 701 Rule For COP leave (CA 1 on file) 04. Begin Work Wed LWOP (See reverse) For Advanced Sick leave (1221 on file). 05. Sick (See reverse) For Military leave (Orders reviewed) Lunch-Out Thur Late For Court leave (Summons reviewed) 06. Lunch-in COP For Higher Level (I 723 on Me) Fri 07. Other: Scheme Training Testing, Qualifying (Memo on file) End Work Sat Remarks (Do not enter medical information).

2 08. Total Hours Sun 09. I understand that the annual leave authorized in excess of amount available to me during the leave year will be changed to LWOP. Mon Employee's Signature and Date Signature of Person Recording Absence and Date Signature of Supervisor and Date Notified 10. Tue 11. tic Official Action on Application (Return copy of signed Request to employee) Wed Signature of Supervisor and Date 12. Approved, not fmla * Approved, fmla Approved fmla , Pending (See Publication 71) Documentation Noted on Reverse. Thur Disapproved (Give reason): 13. Fri Ineligible for fmla (Estimate eligibility date): Continued on Reverse 14. PS Form 3971, April 2001 (Page I of 2) Warning. The furnishing of false information on this form may result in a fine of not more than $1 0,000 or imprisonment of not more than 5 years, or both. (18 1001). Scheduled Scheduled During This Absence , I Was Incapacitated for Duty by.

3 leave Types (Information Only) PP Year UN- Sickness Undergoing medical , Dental, or Time Card PSDS. leave Type Optical Examination or Treatment Code Code On-the-Job Injury - - Day Init. Hours (Job related) AL- fmla 55/01 32. Off-the-Job injury Sat SL- fmla 56/02 33. Undergoing medical , Dental, or 01. Pregnancy and Confinement Optical Examination or Treatment LWOP - fmla - Part Day 59/05 36. Sun (Not job related) LWOP - fmla - Full Day 60/06 37. Exposed to a Contagious Disease 02. LWOP Lieu - of Sick leave 59/60 20. Mon During This Absence , I Was Unavailable for Duty Because-, LWOP -Proffered 59/60 21. 03. - LWOP Personal Reasons 59/60 22. Sick leave for Dependent Care Placement of a Child with Employee Tue LWOP -Part Day 59 23. for Adoption or Foster Care 04. Birth of Child - Bonding LWOP -Full Day 60 23. Wed Additional Information Regarding Denial of leave Protection Under fmla : LWOP -AWOL 59/60 24.

4 05. LWOP IOD. - (Not fmla ) - OWCP 49 25. Employee Not Eligible - Less than 1250 Hours Worked. Thur LWOP -Maternity 59/60 26. 06. Employee Not Eligible -- Not Employed with USPS 1 Year LWOP Suspension - 59/60 27. - Fri LWOP Union Official 84 28. Employee Has Exhausted fmla Entitlement in Current leave Year. 07. LWOP Suspension - Pending Absence Not for a Covered Condition. Sat Termination 59/60 29. 08. Absence Not for a Covered Family Member. Continuation of Pay- USPS 71 03. - USPS- fmla 71/03 Sun Continuation of Pay 34. Requested Documentation Not Provided, 09. Continuation of Pay fmla -IOD-OWCP 49/04 35. Documentation Provided. Does Not Meet Criteria for fmla Protection. Mon Court Duty 61 04. 10. Additional Documentation Required Military leave 67 05 I. 89. Tue Postmaster's Organization 08. 11. Blood Donor leave 69 09. Wed Other Paid leave 86 10. 12. Convention leave 66 12. Thur Acts of God 78 13.

5 13. Privacy Act: The collection of this information is authorized by 39 USC 401. 1001, 1003. 1005; 5 Veteran's Funeral 86 10. Fd JSC 8339; and Public Law 103-3. This information will be used to grant or deny your Request for Relocation 80 15. 14. official leave from Postal Service duty. It may be disclosed under the routine uses given in Privacy Civil Defense 77 16. Act system notices USPS and USPS (see appendix of Administrative Support Civil Disorder 81 17. Manual or, if you wish to obtain a copy of these notices contact your personnel office). Completion Voting leave 85 18. of this form is voluntary. If this information is not provided. Official leave may not be granted. PS Form 3971, April 2001 (Page 2 of 2).