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The Employee Leave Request form serves as a vital tool for employees seeking authorized absences from work due to various circumstances, including personal illness, family care, or other justifications. This form requires several key pieces of information, beginning with the employee’s name and last four digits of their Social Security Number, as well as the organization they belong to. Additionally, it outlines the type of leave being requested—whether it is annual leave, sick leave, or leave without pay—along with the specific dates and times applicable to the request. Employees must specify the purpose of the leave, which may include circumstances related to family and medical issues, such as caring for a seriously ill family member or addressing health care needs of the employee themselves. The form also includes a section for remarks and requires the employee's signature, underscoring their acknowledgment of the policies governing leave requests. This process fosters accountability and transparency within organizations, as approval or disapproval of leave requests by supervisors must be documented, ensuring that management adheres to the regulations set forth under the Family and Medical Leave Act of 1993. Importantly, a Privacy Act Statement is included, highlighting how submitted information is used and the conditions under which it may be shared with other governmental entities, thereby protecting the interests of both the employee and the employer in compliance with federal regulations.

Employee Leave Request Example

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

Get Employee Leave Request PDF Form

Form Characteristics

Fact Name Details
Name Requirement Employees must provide their full legal name (last, first, middle) on the form.
Social Security Number Only the last four digits of the employee’s Social Security Number (SSN) are required.
Leave Type Specification Applicants must specify the type of leave being requested, including options for family and medical leave.
Time Frame The leave request must include specific start and end dates, as well as the total hours of leave requested.
Certification Requirement Employees must certify that the leave requested is for legitimate purposes, acknowledging potential repercussions for falsification.
Supervisor’s Role Approval or disapproval of the request must be documented by the supervisor, who is also responsible for providing reasons in case of disapproval.
Privacy Act Statement The collection of information is governed by Section 6311 of Title 5, United States Code, which outlines usage by management and payroll offices.
Documentation Requirements Medical certification may be required for certain leave requests, particularly when invoking family and medical leave entitlements.
Regulation Reference In the context of federal employees, the governing law is the Family and Medical Leave Act (FMLA) of 1993, along with related provisions under 5 CFR, specifically 5 CFR 630.

Guidelines on Utilizing Employee Leave Request

After gathering the necessary information, you'll be ready to fill out the Employee Leave Request form. It’s important to complete this form accurately to ensure timely processing of your leave request. Below are the steps you should follow to complete the form effectively.

  1. Enter Your Name: Write your full name in the designated space, including your last name, first name, and middle initial if applicable.
  2. Input Your Employee or Social Security Number: Enter only the last four digits of your Social Security Number.
  3. Provide Your Organization: State the name of the organization where you are employed.
  4. Specify the Type of Leave: Indicate the type of leave or absence you are requesting and fill in the appropriate dates and times.
  5. Select Family and Medical Leave Checkboxes: Check the appropriate box(es) that apply to your request for leave under the Family and Medical Leave Act.
  6. Indicate the Leave Type: Specify the type of leave you plan to use (Annual Leave, Sick Leave, etc.), and if necessary, provide additional information as required.
  7. Fill Out the Purpose: Clearly state the purpose for your leave request, such as illness or family care.
  8. Write Remarks if Needed: Use this section to add any additional information relevant to your request.
  9. Sign and Date: Certify your request by signing your name and writing the date of submission.
  10. Supervisor’s Section: Once your request is reviewed, your supervisor will fill out their section indicating approval or disapproval, including their signature and date.

Once completed, your form will be submitted for processing. Make sure to keep a copy for your records, and don't hesitate to follow up with your supervisor if you have any questions during the process.

What You Should Know About This Form

What information do I need to provide on the Employee Leave Request form?

You must provide your name, the last four digits of your Social Security Number, and your organization. Additionally, you'll be asked to specify the type of leave or absence, along with the dates and times for your requested leave. If applicable, detail your accrued leave, including annual and sick leave, and mention any specific reasons for requesting Family and Medical Leave. Finally, you need to sign and date the certification section of the form.

What types of leave can I request using this form?

This form allows you to request various types of leave, including annual leave, sick leave, and leave without pay. Moreover, it accommodates Family and Medical Leave for situations such as the birth or adoption of a child, caring for a seriously ill family member, or your own medical needs. Always check the boxes that apply to your specific situation to ensure accurate processing of your request.

How do I know if my leave request has been approved?

What should I do if I need to submit medical certification?

If your agency requires medical certification, they will inform you when you submit your leave request. Typically, this documentation is needed when requesting Family and Medical Leave. Ensure that your healthcare provider completes the necessary forms indicating the reason for your leave. Remember to submit this documentation promptly to avoid delays in processing your request.

What are the consequences of falsifying information on the form?

Falsification of information on the Employee Leave Request form can lead to serious consequences, including disciplinary action up to removal from your position. The certification section explicitly states that the information you provide must be truthful and accurate. Always provide honest information to maintain your standing within your organization.

Common mistakes

Filling out the Employee Leave Request form may seem straightforward, but there are common mistakes that can lead to complications or even denial of leave. Understanding these pitfalls can help ensure that your request is processed smoothly and efficiently.

One frequent mistake is failing to provide the full name as requested. The form specifically asks for the last name, followed by the first and middle names. Omitting any part can lead to confusion and delays in processing. It's best to take a moment to ensure that your name is entered correctly and completely to avoid unnecessary complications.

Another common error is not entering the last four digits of the Social Security Number correctly. This number is crucial for identification and processing your leave request. Take extra care when entering these digits; a simple typo can result in your application being misfiled or not found at all.

Many individuals also overlook the importance of detailing the type of leave or absence and the relevant dates. This section requires you to check the appropriate boxes and fill in the dates accurately. Failure to do so can result in the request being deemed incomplete. Always double-check your selections to confirm they align with your intended leave.

Additionally, people often neglect to provide sufficient context in the remarks section. This area is not just for additional comments but can also be where you clarify the purpose behind your leave. Providing a well-explained reason can help your supervisor understand the necessity of your request, enhancing the likelihood of approval.

Moreover, some individuals forget to sign the form or tough to submit it before the due date. A signature validates the request, and without it, the form may not be considered complete. Likewise, failing to submit it on time can lead to missed opportunities for leave; every agency has its own deadlines that must be adhered to.

Lastly, a critical mistake involves ignoring the requirement for medical certifications if requested. If your leave is for medical reasons, be prepared to provide necessary documentation. Failing to submit this can lead to disapproval of your leave request, as agencies are mandated to verify such absences for record-keeping and compliance purposes.

By being aware of these common pitfalls, employees can submit their leave requests with confidence. Careful attention to detail in each section of the form will support a smoother process and increase the chances of leave approval.

Documents used along the form

When submitting an Employee Leave Request form, there are several other documents that may be required to support the request. Each serves a specific purpose in the leave application process. Here’s a brief overview of these commonly used forms.

  • Medical Certification Form: This form may be necessary to verify the need for medical leave. It must be completed by a healthcare provider and should detail the nature of the medical condition.
  • Leave Policy Overview: This document outlines the organization’s policies regarding different types of leave. Employees can refer to it to understand their rights and responsibilities when requesting leave.
  • Sick Leave Request Form: If the leave request is specifically for illness, this form may be required. It allows employees to specify the type of sick leave they are requesting.
  • FMLA Leave Request Form: For leaves under the Family and Medical Leave Act, this specific form is used. It outlines the eligibility and the reasons one may qualify for FMLA leave.
  • Leave Accrual Statement: This document details how much leave an employee has accrued and is eligible to use. It helps determine if there will be any unpaid leave taken during the absence.

Being prepared with these documents can help streamline the process of obtaining leave. Always consult with your supervisor or human resources department if you have questions about what is required.

Similar forms

The Employee Leave Request form shares similarities with several other documents related to employee leave and absences. Here’s a list of eight comparable documents and how they align with the Employee Leave Request form:

  • FMLA Leave Request Form: This form is specifically used to request leave under the Family and Medical Leave Act. Like the Employee Leave Request form, it captures a variety of leave types and requires medical documentation for certain claims.
  • Sick Leave Request Form: Employees use this form to request sick leave. Both documents require details about the type of leave and the dates, along with a certification of the medical necessity, if applicable.
  • Vacation Request Form: Employees submit this form to request vacation days. Similar to the Employee Leave Request form, it typically includes information such as names, dates, and the gross number of days needed.
  • Personal Leave Request Form: This document allows employees to request personal days off for reasons other than illness. Like the Employee Leave Request form, it includes spaces for dates and requires employee signatures.
  • Leave of Absence Form: Used for extended periods away from work, this form provides details on the duration and type of leave. It too necessitates signatures and may call for additional documentation.
  • Compassionate Leave Request Form: Similar to the Employee Leave Request form, this document is for employees needing leave due to a family member's death or serious illness. It captures similar information and may require a personal statement.
  • Bereavement Leave Request Form: Employees use this to request leave due to the death of a loved one. Similarities include the need for date ranges and a description of the reason for leave.
  • Disability Leave Request Form: This form is used to request leave due to a disability. Like the Employee Leave Request form, it may involve medical certification and detail the nature and purpose of the leave.

Dos and Don'ts

When filling out the Employee Leave Request form, it’s crucial to approach the task with care. Below is a list of things you should and shouldn’t do to ensure a smooth process.

  • Do provide your full name as listed in official records.
  • Do enter only the last four digits of your Social Security Number for privacy reasons.
  • Do specify the type of leave clearly to avoid misunderstandings.
  • Do include exact dates and times for your leave request.
  • Do mention any medical conditions or reasons in the remarks section if applicable.
  • Do read all instructions carefully before submitting the form.
  • Do keep a copy of the filled form for your records.
  • Don't forget to sign and date the form before submission.
  • Don't falsify information; honesty is key as it could lead to disciplinary action.
  • Don't neglect to follow your agency's procedures for requesting leave.

Following this guidance will help streamline your leave request process and minimize any potential issues. Approach the task thoughtfully, and you will increase the likelihood of your request being approved without complications.

Misconceptions

  • Misconception 1: The Employee Leave Request form is only for planned vacations.

    Many employees believe that this form is exclusively for planned annual leave or vacations. However, it is intended for various types of leave, including sick leave, family leave, and even leave without pay. Employees can request leave for a multitude of reasons, such as personal illness, caring for a family member, or taking time off for a new child.

  • Misconception 2: Providing only the last four digits of my Social Security Number is optional.

    Some employees think that entering the last four digits of their Social Security Number is just a suggestion. In truth, this is required for identification and processing purposes. While more sensitive details are usually not needed, omitting this information could delay the approval of the leave request.

  • Misconception 3: Medical certification is always required for leave requests.

    Not all leave requests necessitate medical certification. This requirement usually applies to specific types of leave, especially when it pertains to medical conditions. In cases such as bereavement or personal time off, employees might not need to provide any medical documentation.

  • Misconception 4: Once the form is submitted, I have no further responsibilities.

    Submitting the form does not exempt employees from following additional procedures. After submission, it is critical to comply with the employing agency's policies regarding leave documentation and confirmation. This may involve ongoing communication with supervisors or personnel offices, particularly if the leave is disapproved.

  • Misconception 5: Disapproval of a leave request is arbitrary and does not require explanation.

    Employees may assume that if their request is disapproved, no explanation is necessary. However, the form requires supervisors to provide a reason for denial. Understanding the basis of disapproval can help employees address issues or misunderstandings in future requests.

Key takeaways

Filling out the Employee Leave Request form is an essential process for all employees seeking time off. Here are some key takeaways to keep in mind:

  • Accurate Information: Ensure that your name, employee number, and organization details are filled out correctly. Inaccuracies can lead to delays in processing your request.
  • Type of Leave: Clearly indicate the type of leave you are requesting, whether it's for personal illness, family care, or other reasons. This information is critical for your supervisor's approval.
  • Medical Certification: Be prepared to provide medical certification if required. This is especially important for serious health conditions and helps to validate your request.
  • Comply with Procedures: Follow your agency's procedures for submitting the form. Missing steps can result in your request being denied or delayed.
  • Review Disapproval Reasons: If your leave request is disapproved, carefully review the provided reasons. Understanding these can help you adjust future requests.
  • Confidentiality: Be aware of the Privacy Act implications. Your information may be shared with specific agencies for administrative purposes, but it should be handled sensitively.

Remember, taking the time to fill out this form accurately can lead to a smoother approval process and ensure that you receive the leave you need.

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