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...Request for leave or approved absence name last first middle employee social security number enter only the digits of ssn organization type date time total family and medical check appropriate box es below from to hours accrued annual if sick without pay will be used restored under act please provide advanced following information i hereby invoke my entitlement birth adoption foster care purpose illness injury incapacitation requesting serious health condition dental optical examination spouse son daughter parent member including bereavement self with a contact your supervisor other personnel office obtain additional about compensatory off entitlements responsibilities paid certification specify in remarks may required by agency duty as indicated above certify that such is requested s understand must comply employing procedures documentation falsification on this form grounds disciplinary action removal signature b official disapproved give reason initiate reschedule disapproval c d pr...