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The Employee Leave Request form serves as a crucial tool for employees navigating their time away from work, ensuring that both their needs and the organization’s protocols are respected. This form requires essential information such as the employee’s name, the last four digits of their Social Security Number, and their organization. It details the type of leave being requested, whether it be for family and medical reasons, annual leave, or sick leave, along with specific dates and times. Employees must indicate the purpose of their leave, which can range from personal illness to caring for a family member or even bereavement. The form also includes a certification section where employees affirm the accuracy of their request and acknowledge their obligation to follow agency procedures. Additionally, the privacy of the information provided is protected under the Privacy Act, ensuring that the data is used appropriately for payroll and leave management. Understanding how to complete this form accurately can significantly impact an employee's ability to take necessary time off while maintaining compliance with workplace policies.

Sample - Employee Leave Request Form

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

File Specs

Fact Name Details
Purpose of the Form The Employee Leave Request form is used to formally request time off from work for various reasons, including personal health issues, family needs, or other approved absences.
Required Information Employees must provide their name, last four digits of their Social Security Number, organization, and specific details about the type of leave requested.
Types of Leave The form accommodates various leave types, including annual leave, sick leave, Family and Medical Leave, and leave without pay.
Certification Requirement Employees must certify that their request is valid and understand the consequences of falsifying information on the form.
Medical Certification For certain types of leave, especially those related to health conditions, a medical certification may be required by the employer.
Supervisor's Role The supervisor must review and approve or disapprove the leave request, providing reasons for any disapproval.
Privacy Act Compliance The collection of information is authorized under Section 6311 of Title 5, U.S. Code, ensuring confidentiality and proper use of data.
State-Specific Forms Some states may have specific forms or additional requirements based on local labor laws. Always check state regulations for compliance.
Legal References Federal laws, such as the Family and Medical Leave Act (FMLA) and Public Law 104-134, govern the use and administration of leave requests.

Employee Leave Request - Usage Guidelines

After completing the Employee Leave Request form, submit it to your supervisor or personnel office for review. They will process your request and inform you of the outcome. Follow the steps below to ensure accurate completion of the form.

  1. Enter your Name in the format of last name, first name, and middle initial.
  2. Provide the last four digits of your Employee or Social Security Number (SSN).
  3. Fill in your Organization.
  4. Indicate the Type of Leave/Absence you are requesting and provide the Date and Time for the leave.
  5. For Family and Medical Leave, check the appropriate box(es) and specify the From and To dates, along with the Total Hours of leave.
  6. If applicable, indicate the type of leave being used: Annual Leave, Accrued Sick Leave, Advanced Annual Leave, or Leave Without Pay.
  7. In the Remarks section, provide any additional information required for your leave request.
  8. Sign and date the form in the Certification section, confirming that the leave is requested for the stated purpose and that you understand the agency's procedures.
  9. Leave the Official Action on Request section blank for your supervisor to complete.

Your Questions, Answered

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

When completing the Employee Leave Request form, you must provide several key pieces of information. Start with your name, including your last, first, and middle names. Next, include the last four digits of your Social Security Number. You will also need to specify your organization and the type of leave or absence you are requesting. Be sure to indicate the dates and times of your leave, as well as the total hours. If applicable, check the appropriate boxes for Family and Medical Leave and detail the purpose of your request. Lastly, include any remarks and sign the form to certify your request.

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, leave without pay, and Family and Medical Leave. You can also request leave for specific reasons such as birth, adoption, illness, or caring for a family member with a serious health condition. If you plan to use accrued leave or request advanced leave, ensure you indicate this clearly on the form. Each type of leave has specific guidelines, so be sure to review your agency's policies for any additional requirements.

What happens if my leave request is disapproved?

If your leave request is disapproved, your supervisor will provide a reason for the denial. This information is crucial as it helps you understand any potential issues or misunderstandings regarding your request. In the case of annual leave, your supervisor may initiate action to reschedule your leave. It is advisable to communicate with your supervisor to address any concerns and explore alternative options if your request is not approved.

Do I need to provide medical certification for my leave request?

In certain circumstances, you may be required to provide medical certification to support your leave request, especially if you are invoking Family and Medical Leave. Your agency will inform you if this documentation is necessary. It is essential to comply with this requirement to ensure your leave is properly authorized. Failure to provide required documentation could result in delays or denial of your leave request.

Common mistakes

  1. Incomplete Name Information: Many people forget to include their full name, including last, first, and middle names. This can lead to confusion and delays in processing the request.

  2. Incorrect Social Security Number: Entering the wrong last four digits of the Social Security Number can cause issues with identification and payroll.

  3. Missing Dates: Failing to provide the start and end dates of the leave can result in the request being denied. Always double-check that these fields are filled out completely.

  4. Not Specifying Type of Leave: It’s crucial to check the appropriate box for the type of leave requested. Omitting this detail can lead to misunderstandings about the nature of the leave.

  5. Inadequate Remarks: Some individuals neglect to provide enough information in the remarks section. This can be especially important for medical leave, where additional context may be required.

  6. Failure to Sign: Forgetting to sign and date the form can halt the entire process. Always remember to complete this final step before submission.

  7. Ignoring Agency Procedures: Each agency may have specific rules for submitting leave requests. Not following these can lead to disapproval or delays.

Documents used along the form

When submitting an Employee Leave Request form, several other documents may also be required or helpful for processing the request. These documents provide additional information and support for the leave being requested. Below is a list of common forms and documents that are often used alongside the Employee Leave Request form.

  • Medical Certification Form: This document is used to verify the medical condition that necessitates the employee's leave. It must be completed by a healthcare provider and may include details about the diagnosis and treatment plan.
  • Leave of Absence Policy: This document outlines the organization's policies regarding various types of leave, including eligibility, duration, and procedures for requesting leave. Employees should review this to understand their rights and responsibilities.
  • Return to Work Form: After a leave of absence, this form is often required to confirm that the employee is fit to return to work. It may also include any necessary restrictions or accommodations needed upon return.
  • Family and Medical Leave Act (FMLA) Notice: This notice informs employees of their rights under the FMLA. It provides details on how to apply for FMLA leave and what documentation is necessary.
  • Annual Leave Balance Statement: This document shows the employee's current leave balance. It helps determine how much annual leave can be used for the requested absence.
  • Supervisor's Approval Form: This form is often required to document the supervisor's approval or disapproval of the leave request. It may also include comments or reasons for any disapproval.
  • Compensatory Time Off Request Form: If applicable, this form is used to request time off that has been earned through overtime work. It provides a way to account for extra hours worked.
  • Bereavement Leave Request Form: This form is specifically for requesting leave due to the death of a family member. It may require details about the relationship and the circumstances surrounding the leave.

Having these documents ready can streamline the leave request process and ensure that all necessary information is provided. Employees should consult their HR department if they have questions about any of these forms or need assistance completing them.

Similar forms

The Sick Leave Request form is similar to the Employee Leave Request form in that both documents require employees to specify the type of leave they are requesting. Each form captures essential information such as the employee's name and identification number, which helps to maintain accurate records. Additionally, both forms may necessitate a medical certification if the leave is due to health-related issues, ensuring that the request is valid and documented appropriately.

The Family Leave Request form also shares similarities with the Employee Leave Request form. This document is specifically designed for employees needing time off to care for a family member with a serious health condition. Like the Employee Leave Request form, it requires details about the employee and the nature of the leave. Furthermore, both forms emphasize compliance with agency procedures and may require supporting documentation.

The Vacation Request form is another document that parallels the Employee Leave Request form. Both forms allow employees to request time away from work for personal reasons, whether for leisure or family matters. Each form includes sections for the employee's name and the specific dates of the requested leave, ensuring that supervisors can manage scheduling effectively.

The Bereavement Leave Request form is similar to the Employee Leave Request form as it provides a structured way for employees to request time off following the death of a loved one. Both forms require the employee's information and outline the type of leave being requested. In both cases, the documentation helps employers understand the reasons behind the absence and manage workloads accordingly.

The Leave of Absence Request form shares key features with the Employee Leave Request form. This document is used when an employee needs to take an extended period away from work for various reasons, such as personal issues or health concerns. Both forms require detailed information about the employee and the duration of the leave, facilitating proper planning and communication within the organization.

The Compensatory Time Off Request form is another document that aligns with the Employee Leave Request form. Employees use this form to request time off in exchange for extra hours worked. Similar to the Employee Leave Request form, it requires the employee's name and the specific dates for the time off, helping supervisors track and approve requests efficiently.

The Medical Leave Request form is akin to the Employee Leave Request form in that it specifically addresses absences due to medical reasons. Both forms require the employee to provide personal information and may necessitate medical documentation to validate the request. This ensures that the leave is appropriately categorized and that the employee’s rights are protected under relevant laws.

The Personal Leave Request form is similar to the Employee Leave Request form, as it allows employees to take time off for personal reasons not covered by other leave types. Each form requires similar information about the employee and the reason for the absence. This helps maintain transparency and ensures that all requests are handled consistently.

The Maternity Leave Request form is another document that mirrors the Employee Leave Request form. It is specifically designed for employees expecting a child and outlines the time off needed for maternity purposes. Both forms require the employee's identification and the dates of the requested leave, ensuring that the organization can plan for the employee's absence effectively.

The Flexible Work Arrangement Request form also shares similarities with the Employee Leave Request form. While this document is used to request changes to work schedules rather than leave, it still requires the employee to provide personal information and details about the requested arrangement. Both forms aim to accommodate employees' needs while ensuring that business operations continue smoothly.

Dos and Don'ts

When filling out the Employee Leave Request form, consider the following guidelines:

  • Do provide your full name as requested, including last, first, and middle names.
  • Do enter only the last four digits of your Social Security Number (SSN).
  • Do specify the type of leave or absence you are requesting clearly.
  • Don't forget to indicate the exact dates and times for your leave.
  • Don't leave any sections blank; ensure all required information is filled out.
  • Don't falsify any information on the form, as this may lead to disciplinary action.

Misconceptions

  • Misconception 1: The Employee Leave Request form is only for sick leave.

    This is not true. While the form does allow for sick leave requests, it covers various types of leave, including annual leave, family and medical leave, and leave without pay. Employees can use this form to request time off for a range of personal and family-related reasons.

  • Misconception 2: Submitting the form guarantees approval of leave.

    Approval is not automatic upon submission. The request is subject to review by a supervisor or personnel office. They will evaluate the request based on agency policies and the reasons provided. Disapproval can occur, and the employee will be informed of the reasons.

  • Misconception 3: Only full-time employees can use the Employee Leave Request form.

    This form is available to all employees, regardless of their work schedule. Part-time employees and those on temporary assignments can also request leave using this form, as long as they follow the appropriate procedures.

  • Misconception 4: Medical certification is always required for leave requests.

    While medical certification may be required for certain types of leave, such as family and medical leave, it is not necessary for all requests. The need for documentation depends on the specific type of leave being requested and the agency's policies.

Key takeaways

Filling out and using the Employee Leave Request form is an important process for managing your time away from work. Here are some key takeaways to keep in mind:

  • Complete Your Information: Make sure to fill in your name, employee number, and organization accurately.
  • Specify Leave Type: Clearly indicate the type of leave you are requesting, whether it’s annual leave, sick leave, or another category.
  • Provide Dates and Times: Include the start and end dates for your leave, along with specific times if necessary.
  • Accrued Leave: If you are using accrued leave, mention how much you have available and which type you intend to use.
  • Certification Requirement: Be aware that some types of leave may require medical certification. Check with your agency for specific requirements.
  • Signature and Date: Don’t forget to sign and date the form to validate your request.
  • Supervisor’s Review: Your supervisor will review your request and provide approval or disapproval. They must also give a reason if your request is denied.
  • Privacy Considerations: Understand that your information is protected under the Privacy Act, but it may be shared with authorized entities for specific purposes.
  • Follow Up: After submitting your request, it’s a good idea to follow up with your supervisor or HR to ensure everything is in order.

By keeping these points in mind, you can navigate the leave request process more smoothly and ensure that your time away from work is managed effectively.