WPC  77WPC >? AC?( [@/?GO/?VO~Qc"8PQc"P?N(= b<$&b^oJbZc7>  (  (Untitled)'3,, , ,   UB ) 3    *    d +    d ,    d /0gjklmnopqrstuvwxyz{|}~P* * f:\inf41\forms\sf71.wpf h:\inf41\forms\bkup\sf71new.wpfUS&&x&&   >]? f eh Terminal 1 ! ZS  d      Terminal eb Arial " ! <S  d    Arial eh Terminal 1 ! ZS  d      Terminal ev Times New Roman  ! <S  d    Times New Roman ef Courier 1 ! ZS  d     Courier en Courier New 1 ! PL5    d      Courier New eb Swiss " ! FS  d    Swiss eb Dutch  ! <S  d    Dutch en Univers ATT " ! FS  d     Univers ATT ex Helvetica-Narrow " ! (5 S  d    Helvetica-Narrow eb Roman  ! 2L   d    Roman eh Helve-WP " ! <S  d     Helve-WP ej Wingdings  ! S  d     Wingdings eX  ! <S  d     eh MS Serif  ! <S  d     MS Serif ed Modern 2 ! x."  d    Modern ej Bodoni-WP  ! <S  d     Bodoni-WP er MS Sans Serif " ! FS  d    MS Sans Serif ed System " ! Z@   d    System er CG Times (WN)  ! <S  d    CG Times (WN) ep Times CG ATT  ! <S  d     Times CG ATT ep Arial Narrow " ! (5 S  d     Arial Narrow en LinePrinter 1 ! ZS  d      LinePrinter ed Symbol  ! <S  d    Symbol ef Univers " ! <S  d    Univers ?Ad A{?( z jW c:\inf42\database\ SF71.DBFHistory   i%Name  K   h NAMEK i'EmpSSN  A   h EMPSSNA i$Org     h ORG i(AccrAnn      h ACCRANN  i+FromDate_1     h  FROMDATE_1 i)ToDate_1     h TODATE_1 i+FromTime_1     h  FROMTIME_1 i)ToTime_1     h TOTIME_1 i+TotalHrs_1     h  TOTALHRS_1 i(RestAnn      h RESTANN  i+FromDate_2     h  FROMDATE_2 i)ToDate_2     h TODATE_2 i+FromTime_2     h  FROMTIME_2 i)ToTime_2     h TOTIME_2 i+TotalHrs_2     h  TOTALHRS_2 i'AdvAnn      h ADVANN  i+FromDate_3     h  FROMDATE_3 i)ToDate_3     h TODATE_3 i+FromTime_3     h  FROMTIME_3 i)ToTime_3     h TOTIME_3 i+TotalHrs_3     h  TOTALHRS_3 i(AccSick      h ACCSICK  i+FromDate_4     h  FROMDATE_4 i)ToDate_4     h TODATE_4 i+FromTime_4     h  FROMTIME_4 i)ToTime_4     h TOTIME_4 i+TotalHrs_4     h  TOTALHRS_4 i(AdvSick      h ADVSICK  i+FromDate_5     h  FROMDATE_5 i)ToDate_5     h TODATE_5 i+FromTime_5     h  FROMTIME_5 i)ToTime_5     h TOTIME_5 i+TotalHrs_5 !    h  TOTALHRS_5 i(MedExam  "    h MEDEXAM  i*CareOfFam  #    h CAREOFFAM  i&Other  $    h OTHER  i)CompTime  %    h COMPTIME  i+FromDate_6 &    h  FROMDATE_6 i)ToDate_6 '    h TODATE_6 i+FromTime_6 (    h  FROMTIME_6 i)ToTime_6 )    h TOTIME_6 i+TotalHrs_6 *    h  TOTALHRS_6 i(OthPaid  +    h OTHPAID  i+FromDate_7 ,    h  FROMDATE_7 i)ToDate_7 -    h TODATE_7 i+FromTime_7 .    h  FROMTIME_7 i)ToTime_7 /    h TOTIME_7 i+TotalHrs_7 0    h  TOTALHRS_7 i+WithoutPay  1    h  WITHOUTPAY  i+FromDate_8 2    h  FROMDATE_8 i)ToDate_8 3    h TODATE_8 i+FromTime_8 4    h  FROMTIME_8 i)ToTime_8 5    h TOTIME_8 i+TotalHrs_8 6    h  TOTALHRS_8 i*InvokeEnt  7    h INVOKEENT  i&Birth  8    h BIRTH  i'Spouse  9    h SPOUSE  i%Self  :    h SELF  i(Remarks  ;    h REMARKS  i'EmpSig  <    h EMPSIG i+EmpSigDate =    h  EMPSIGDATE i)Approved  >    h APPROVED  i+Disapprovd  ?    h  DISAPPROVD  i'Reason @    h REASON i*Signature  A    h SIGNATURE i(SigDate B    h SIGDATE B % NAME Character K ' EMPSSN Character A $ ORG Character  & ACCRANN Logical   & FROMDATE_1 Date  $ TODATE_1 Date  + FROMTIME_1 Character   ) TOTIME_1 Character   ) TOTALHRS_1 Numeric  & RESTANN Logical   & FROMDATE_2 Date  $ TODATE_2 Date  + FROMTIME_2 Character   ) TOTIME_2 Character   ) TOTALHRS_2 Numeric  % ADVANN Logical   & FROMDATE_3 Date  $ TODATE_3 Date  + FROMTIME_3 Character   ) TOTIME_3 Character   ) TOTALHRS_3 Numeric  & ACCSICK Logical   & FROMDATE_4 Date  $ TODATE_4 Date  + FROMTIME_4 Character   ) TOTIME_4 Character   ) TOTALHRS_4 Numeric  & ADVSICK Logical   & FROMDATE_5 Date  $ TODATE_5 Date  + FROMTIME_5 Character   ) TOTIME_5 Character   ) TOTALHRS_5 Numeric  & MEDEXAM Logical   ( CAREOFFAM Logical   $ OTHER Logical   ' COMPTIME Logical   & FROMDATE_6 Date  $ TODATE_6 Date  + FROMTIME_6 Character   ) TOTIME_6 Character   ) TOTALHRS_6 Numeric  & OTHPAID Logical   & FROMDATE_7 Date  $ TODATE_7 Date  + FROMTIME_7 Character   ) TOTIME_7 Character   ) TOTALHRS_7 Numeric  ) WITHOUTPAY Logical   & FROMDATE_8 Date  $ TODATE_8 Date  + FROMTIME_8 Character   ) TOTIME_8 Character   ) TOTALHRS_8 Numeric  ( INVOKEENT Logical   $ BIRTH Logical   % SPOUSE Logical   # SELF Logical   # REMARKS Memo    ' EMPSIG Character  & EMPSIGDATE Date  ' APPROVED Logical   ) DISAPPROVD Logical   ' REASON Character  * SIGNATURE Character  # SIGDATE Date  ?@d @}?GOuR ( 1. NAME (Last, First, Middle Initial) Name!"-./567(89:(;>?@ABCG                         P #      $      ' K  Y@$.,! *  < Z& = &&     ~  ( 2. EMPLOYEE OR SOCIAL SECURITY  ( NUMBER  EmpSSN!"-./5/6789:;>?@ABCG                         P #      $      ' A  Y@$.,! *  < Z = &&     WR  ( 3. ORGANIZATION  Org!"-./567E89:E;>?@ABCG                         P #      $      '   Y@$.,! *  < Z& = &&     R(  (   4. TYPE OF LEAVE/ABSENCE  (  (Check appropriate box(es)  ( below.)   !"#                             P  Z&    z      DATE     !"#                             P  &&    Vx     TIME  )   !"#                             P  &&         TOTAL   HOURS  4  !"#                             P  &&    f  (   5. FAMILY AND MEDICAL  (  LEAVE  :  !"#                             P  Z&    R w  (     REQUEST FOR LEAVE OR APPROVED ABSENCE  E !"#                             P  &&     V R ( L       P     9 (  Accrued Annual Leave    AccrAnn# $%& '()+,-.                             P   !  * && 1 &&& 2      3       9 (  Restored Annual Leave    RestAnn # $%&'()+,-.                             P   !  * && 1 &&& 2      3     H 9 (  Advance Annual Leave    AdvAnn#$%&'()+,-.                             P   !  * && 1 &&& 2      3     <z  o FromDate_1!"-./56 789:;>?@ABCG                         P #      $      '    Y@$.,! *  < && =      :h o ToDate_1!"-./5#6 789:;>?@ABCG                         P #      $      '    Y@$.,! *  < && =      :V o FromTime_1!"-./5)6 789:;>?@ABCG                         P #      $      '    Y@$.,! *  < && =      8 o ToTime_1!"-./5/6 789:;>?@ABCG                         P #      $      '    Y@$.,! *  < && =      <z  n FromDate_2! "-'./56789:;>?@ABCG                         P #      $      '    Y@$.,! *  < &&& =      :h n ToDate_2! "-(./5#6789:;>?@ABCG                         P #      $      '    Y@$.,! *  < &&& =      :V n FromTime_2! "-)./5)6789:;>?@ABCG                         P #      $      '    Y@$.,! *  < &&& =      8 n ToTime_2!"-*./5/6789:;>?@ABCG                         P #      $      '    Y@$.,! *  < &&& =      <z i o FromDate_3!"-+./56789:;>?@ABCG                         P #      $      '    Y@$.,! *  < &&& =      :hi o ToDate_3!"-,./5#6789:;>?@ABCG                         P #      $      '    Y@$.,! *  < &&& =      :Vi o FromTime_3!"--./5)6789:;>?@ABCG                         P #      $      '    Y@$.,! *  < &&& =      8i o ToTime_3!"-../5/6789:;>?@ABCG                         P #      $      '    Y@$.,! *  < &&& =      <z ^ FromDate_4!"-3./56789:;>?@ABCG                         P #      $      '    Y@$.,! *  < &&& =      :h^ ToDate_4!"-4./5#6789:;>?@ABCG                         P #      $      '    Y@$.,! *  < &&& =      :V^ FromTime_4!"-5./5)6789:;>?@ABCG                         P #      $      '    Y@$.,! *  < &&& =      8^ ToTime_4!"-6./5/6789:;>?@ABCG                         P #      $      '    Y@$.,! *  < &&& =      <z 6^ FromDate_5!"-7./56789:;>?@ABCG                         P #      $      '    Y@$.,! *  < &&& =      :h6^ ToDate_5!"-8./5#6789:;>?@ABCG                         P #      $      '    Y@$.,! *  < &&& =      :V6^ FromTime_5!"-9./5)6789:;>?@ABCG                         P #      $      '    Y@$.,! *  < &&& =      86^ ToTime_5! "-:./5/6789:;>?@ABCG                         P #      $      '    Y@$.,! *  < &&& =      : o TotalHrs_1! "-;./546 789:;>?@ABCG                         P #      $      '    $.,! *  < && = &&     : n TotalHrs_2!"-<./546789:;>?@ABCG                         P #      $      '    $.,! *  < && = &&     :i o TotalHrs_3!"-=./546789:;>?@ABCG                         P #      $      '    $.,! *  < && = &&     ??VO:^ TotalHrs_4!"->./546789:;>?@ABCG                         P #      $      '    $.,! *  < && = &&     :6^ TotalHrs_5!!"-?./546789:;>?@ABCG                         P #      $      '    $.,! *  < && = &&      9 (  Compensatory Time Off    CompTime%#@$%&'()+,-.                             P   !  * && 1 &&& 2      3     v9 (  Other Paid Absence    OthPaid+#A$%&'()+,-.                             P   !  * && 1 &&& 2      3     9 (  Leave Without Pay    WithoutPay1#B$%&'()+,-.                             P   !  * && 1 &&& 2      3      V R(  C      P     V Rj(  D      P     V RD( & E      P    h9 (  Advance Sick Leave    AdvSick#F$%&'()+,-.                             P   !  * && 1 &&& 2      3     9 (  Accrued Sick Leave    AccSick#G$%&'()+,-.                             P   !  * && 1 &&& 2      3     >,H ( (Specify in Remarks)    !"#                             P  &&    ,I     Purpose:   !"#                             P  &    3 , (  Medical/dental/optical examination of requesting employee   MedExam"#J$% &' ()+,-.                             P   !  * && 1 &&& 2      3      MedExam=true   MedExam        @resetobj(MedExam)    MedExam    4@resetobj(CareOfFam); @resetobj(Other) "  CareOfFam       Other    [R( L  !"#                             P  &&    4M (   examination of family member  !"#                             P  &    ?\, (  Care of family member/bereavement, including medical/dental/optical   CareOfFam##N$% &''()+,-.                             P   !  * && 1 &&& 2      3       CareOfFam=true    CareOfFam       "@resetobj(CareOfFam) "  CareOfFam    2@resetobj(MedExam); @resetobj(Other)    MedExam       Other     , (  Other   Other$#P$%1&'()+,-.                             P   !  * && 1 &&& 2      3      Other=true   Other       @resetobj(Other)   Other    6@resetobj(CareOfFam); @resetobj(MedExam) "  CareOfFam        MedExam    H fQ (   If annual leave, sick leave, or  ( leave without pay will be used  ( under the Family and Medical  ( Leave Act of 1993, please provide  ( the following information: :  !"#                             P  &&    bfLR   Contact your supervisor and/or your   personnel office to obtain additional   information about your entitlements   and responsibilities under the Family   and Medical Leave Act of 1993. : !"#                             P  &     n, n   I hereby invoke my entitlement    InvokeEnt7#S$%;&'()+,-.                             P   !  * &&& 1 &&& 2      3       InvokeEnt=TRUE    InvokeEnt       X@resetobj(Birth); @resetobj(Spouse); @resetobj(Self); @resetobj(InvokeEnt)   Birth       Spouse       Self     "  InvokeEnt       >JT n   to Family and Medical Leave for:  = !"#                             P  &     V#B U      P    0;, n Birth/Adoption/Foster Care  d dBirth8#V$%<&' ()+,-.                             P   !  * && 1 &&& 2      3      Birth=true   Birth       @resetobj(Birth)   Birth    0@resetobj(Spouse); @resetobj(Self)   Spouse       Self    \;, n Serious Health Condition of  d dSpouse9#W$%<&' ()+,-.                             P   !  * && 1 &&& 2      3       Spouse=true   Spouse       @resetobj(Spouse)   Spouse    /@resetobj(Birth); @resetobj(Self)   Birth       Self    ;, n Serious Health Condition of  d dSelf:#X$%<&' ()+,-.                             P   !  * && 1 &&& 2      3       Self=true   Self       @resetobj(Self)   Self    1@resetobj(Spouse); @resetobj(Birth)   Spouse       Birth    V,Y n  Spouse, Son, Daughter, or  n Parent = !"#                             P  &    vZ n  Self = !"#                             P  &     V [      P    <z  FromDate_6!&"-\./56789:;>?@ABCG                         P #      $      '    Y@$.,! *  < &&& =      <z D& FromDate_7!,"-]./56789:;>?@ABCG                         P #      $      '    Y@$.,! *  < &&& =      <z j FromDate_8!2"-^./56789:;>?@ABCG                         P #      $      '    Y@$.,! *  < &&& =      :h ToDate_6!'"-_./5#6789:;>?@ABCG                         P #      $      '    Y@$.,! *  < &&& =      :hD& ToDate_7!-"-`./5#6789:;>?@ABCG                         P #      $      '    Y@$.,! *  < &&& =      :hj ToDate_8!3"-a./5#6789:;>?@ABCG                         P #      $      '    Y@$.,! *  < &&& =      :V FromTime_6!("-b./5)6789:;>?@ABCG                         P #      $      '    Y@$.,! *  < &&& =      :VD& FromTime_7!."-c./5)6789:;>?@ABCG                         P #      $      '    Y@$.,! *  < &&& =      ?tQc"WPC') ) 9*  ) HH !}O?5 5 ?5 4 ?4 4 4 4 4 4 4 4 ?4 ?4 ?3 ?3 3 ?3 ?3 3 3 3 3 3 3?3333??3?33333   ?    ?  ?    ??  8<?08 ?  ????  ????? ? ?   ?  ? ? ??      ??  ?  ? ?~~?~ ??>| ??p??< >?0??8 ?? ????? p ?0++++?+?x3xx??3||??3<<? 3>? 3??>?3???6?.? - -??  <??? .?  -@?@ ?  ?  ' ?  ?  |???  ~,?| ,<? |,x ?>?"? ??"?? "? !?? ?!?? !? ??  p   ~? ? ? ? ? ??? ??? ?   ? ???   | ~???>? :?0!p  ? ? ???? ? ??? ?? ?" ' ' ' ?( ?( ( ( ( ?( ( ( ( ( ( ?(? ??(? x??( 8?( ( ( ( ( ?( ( ( 8 9 9 9 9 9 8 8 ?8 ?8 ?8 8 8 8 8 8? 8?8?8?8?9?9999999:<?<<==OQP PQc"WPC') ) 9*  ) HH !}O?5 5 ?5 4 ?4 4 4 4 4 4 4 4 ?4 ?4 ?3 ?3 3 ?3 ?3 3 3 3 3 3 3?3333??3?33333   ?    ?  ?    ??  8<?08 ?  ????  ????? ? ?   ?  ? ? ??      ??  ?  ? ?~~?~ ??>| ??p??< >?0??8 ?? ????? p ?0++++?+?x3xx??3||??3<<? 3>? 3??>?3???6?.? - -??  <??? .?  -@?@ ?  ?  ' ?  ?  |???  ~,?| ,<? |,x ?>?"? ??"?? "? !?? ?!?? !? ??  p   ~? ? ? ? ? ??? ??? ?   ? ???   | ~???>? :?0!p  ? ? ???? ? ??? ?? ?" ' ' ' ?( ?( ( ( ( ?( ( ( ( ( ( ?(? ??(? x??( 8?( ( ( ( ( ?( ( ( 8 9 9 9 9 9 8 8 ?8 ?8 ?8 8 8 8 8 8? 8?8?8?8?9?9999999:<?<<==OQP  P?N:Vj FromTime_8!4"-d./5)6789:;>?@ABCG                         P #      $      '    Y@$.,! *  < &&& =      8 ToTime_6!)"-e./5/6789:;>?@ABCG                         P #      $      '    Y@$.,! *  < &&& =      8D& ToTime_7!/"-f./5/6789:;>?@ABCG                         P #      $      '    Y@$.,! *  < &&& =      8j ToTime_8!5"-g./5/6789:;>?@ABCG                         P #      $      '    Y@$.,! *  < &&& =      : TotalHrs_6!*"-h./546789:;>?@ABCG                         P #      $      '    $.,! *  < && = &&     :D& TotalHrs_7!0"-i./546789:;>?@ABCG                         P #      $      '    $.,! *  < && = &&     :j TotalHrs_8!6"-j./546789:;>?@ABCG                         P #      $      '    $.,! *  < && = &&     WR  ( 6. REMARKS:  Remarks!;"-k./56!7E89:E;>?@ABCG                         P #      $      '  0  Y@$.,! *  < Z&& = &&     ~z  l   From:    !"#                             P  &&x    |h m   To:  #  !"#                             P  &&x    ~V n   From:  )  !"#                             P  &&x    | o   To:  /  !"#                             P  &&x    ~R  p   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)  n indicated. I understand that I must comply with my employing agency's procedures for requesting leave/approved absence (and provide additional documentation,  n including medical certification, if required) and that falsification of information on this form may be grounds for disciplinary action, including removal. &E !"#                             P  Z&&    ` ( ^    DATE  ^EmpSigDate!="-r./576*789:;>?@ABCG                         P #      $      ' 0  Y@$.,! *  < &&6 = && 6    8@HASVALUE (EmpSigDate) and #UPDATONLY  !  EmpSigDate  ~      =@datevalue (@datetext (EmpSigDate, "%2-%1-%5")) !  EmpSigDate   %2-%1-%5  "  #  :@VALUE (@DATETEXT (EmpSigDate,"%5"))<=29 !  EmpSigDate   %5  "  x         @SETVALUE (EmpSigDate,@DATEVALUE (@CONCAT (@DATETEXT (EmpSigDate,"%2-%1"),"-20",@DATETEXT (EmpSigDate,"%5"))),TRUE) #  EmpSigDate !  EmpSigDate   %2-%1  "   -20 !  EmpSigDate   %5  "      #       ]p$ ^    DATE  ^SigDate!B"-t./526/789:;>?@ABCG                         P #      $      ' 0  Y@$.,! *  < &&6 = && 6    5@HASVALUE (SigDate) and #UPDATONLY    SigDate  ~      :@datevalue (@datetext (SigDate, "%2-%1-%5"))   SigDate   %2-%1-%5  "  #  7@VALUE (@DATETEXT (SigDate,"%5"))<=29   SigDate   %5  "  x         x@SETVALUE (SigDate,@DATEVALUE (@CONCAT (@DATETEXT (SigDate,"%2-%1"),"-20",@DATETEXT (SigDate,"%5"))),TRUE)    SigDate   SigDate   %2-%1  "   -20   SigDate   %5  "      #       R." Xu   8. OFFICIAL ACTION ON REQUEST:  +E !"#                             P  Zl&      ."~9    APPROVED    Approved>#v$%&+' ()+,-.                             P   !  * &&& 1 &&& 2      3      approved=true   Approved       !@resetobj(approved) !  Approved    #@resetobj(disapprovd) #  Disapprovd    ."9    DISAPPROVED    Disapprovd?#w$%&&+'()+,-.                             P   !  * &&& 1 &&& 2      3      !disapprovd=true !  Disapprovd       #@resetobj(disapprovd) #  Disapprovd    !@resetobj(approved) !  Approved    R& lx n  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  n approve any record you use of leave. Additional disclosures of the information may be: To the Department of Labor when processing a claim for compensation  n regarding a job connected injury or illness; to a State unemployment compensation office regarding a claim; to Federal Life Insurance or Health Benefits carriers  n 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  n a Federal agency when conducting an investigation foremploymentt or security reasons; to the Office of Personnel Management or the General Accounting Office when  n the information is required for evaluation of leave administration; or to the General Services Administration in connection with its responsibilities for records  n management.  n   n Where the employee identification number is your Social Security Number, collection of this information is authorized by Executive Order 9397. Furnishing the  n information on this form, including your Social Security Number, is voluntary, but failure to do so may result in disapproval of this request.  n   n 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  n those purposes.  1E  !"#                             P  Z&&    RH& ^y ((    PRIVACY ACT STATEMENT  1E !"#                             P  &&&    Rp0Bz d This form was electronically produced by Elite Federal Forms, Inc. > !"#                             P  Z    RJ. ^{   U.S. OFFICE OF PERSONNEL MANAGEMENT   AUTHORIZED FOR LOCAL REPRODUCTION ; !"#                             P  Z&&    J. ^|   STANDARD FORM 71 (Rev. 12-97)   PREVIOUS EDITION MAY BE USED 3; !"#                             P  &&&    (#b}   (If disapproved, give reason. If annual leave, initiate action to reschedule.) -% !"#                             P  &&x    6R#  Reason!@"-~./56.7E89:;>?@ABCG                         P #      $      '   Y@$.,! *  < && = &&     C= |@ g      jR &    EMPLOYEE SIGNATURE  &EmpSig!<",-q./56)7/89:;>?@ABCG                         P #      $      '  A  Y@$.,! *  < Z6 = && 6 {? H:\INF41\DATABASE\FHWA.SDB  c) |   |  |   |  |  |   |  |  |  |  |   |  |  |  |   |  |  | ! |  |     C<$@ g      fR$^    SIGNATURE ' ^Signature!A",-s./056/7*89:;>?@ABCG                         P #      $      '  A  Y@$.,! *  < Z6 = && 6 {? H:\INF41\DATABASE\FHWA.SDB  c) |   |  |   |  |  |   |  |  |  |  |   |  |  |  |   |  | ! |  |       ; < = > ? v w ?.= def =g<$defg <^o elite10.DLL IVALID FILLER This form was Designed by Elite Federal Forms and requires the Elite/Novell Filler! Call 410-647-9691 for more information. elite10.COM IVALID FILLER This form was Designed by Elite Federal Forms and requires the Elite/Novell Filler! Call 410-647-9691 for more information. WPIN$ELITE10FunctionSet,4.1 ^=Z1czZ`