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Request for or Notification of Absence Scheduled scheduled Employee's Name (Last, First, M.I.) 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) 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 U.S.C. 1001) Scheduled Scheduled During This Absence, I Was Incapacitated for Duty by. 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 MonDuring 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 WedAdditional Information Regarding Denial of Leave Protection Under FMLA: LWOP -AWOL 59/60 24 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 10Additional 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 13Privacy Act: The collection of this information is authorized by 39 USC 401. 1001, 1003. 1005; 5 Veteran's Funeral 86 10 FdJSC 8339; and Public Law 103-3. This information will be used to grant or deny your request for Relocation 80 15 14official leave from Postal Service duty. It may be disclosed under the routine uses given in Privacy Civil Defense 77 16Act system notices USPS 050.020 and USPS 120.070 (see appendix of Administrative Support Civil Disorder 81 17Manual or, if you wish to obtain a copy of these notices contact your personnel office). Completion Voting Leave 85 18of 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)
Manual or, if you wish to obtain a copy of these notices contact your personnel office). Completion of this form is voluntary. If this information is not provided. Official leave may not be granted. …
When requesting a formal leave of absence, your letter should include: 1 Request for a leave of absence, 2 The dates you expect to be away from work, 3 The date you plan to return to work, 4 An offer to provide assistance, if feasible, 5 Thanks for considering your request. More ...
The most common reasons to request a leave of absence outside of normal PTO include: New child. Maternity and paternity leave are the most common reasons why employees take extended leaves of absence. Different companies might have different policies, but the FMLA covers the bare minimum requirements for coverage (more on that below).
You can order the revised PS Form 3971 through the MDC eBuy+ catalog. Note: Some military sites without eBuy+ access can place orders by contacting their Joint Military Postal Activity (JMPA). * Price is current as of this date but is subject to change. The July 2021 edition of PS Form 3971 is now available on the Postal Service PolicyNet website:
After sending your letter, decide with your supervisor how you will inform your colleagues of your absence. You may need to tell them personally, or someone may take care of it for you. Be sure to give adequate notice to any coworkers who work directly with you or otherwise depend upon your work.