USVI Public Records

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Government of the Virgin Islands REQUEST FOR OR NOTIFICATION ABSENCE PP # Fiscal Year (1) Employee’s Name (Last, First M.I.) (2) Employee No. (4) Date Submitted (5) No. of Hours Requested Day Init. Hours (3) Agency/Division: Account/Activity Code (6) From Date Sun (7) Time of Call or Request (8) Scheduled Reporting Time (9) Employee Can Be Reached At (If Needed) (10)  No Call Thru Date Mon (11) Type of Absence  Sick (See Reverse)  Annual  LWOP (See Reverse)  Maternity  Comp ________ Other (12) Documentation (for Official Use Only)  For Military Leave (Order Reviewed)  For court Leave (Summons Reviewed) (13) Revised Scheduled for Approved in Advance  Yes  No ___________________ (Date) Tue Wed Thur Begin Work Fri Lunch-Out Sat (14) Remarks – (Do Not Enter Medical Information) Lunch-In Sun I Understand that the annual leave authorized in excess of amount available of me during the leave year will be charged to LWOP End Work Mon Total Hours Tue (15) Employee’s Signature & Date (16) Signature of Person Recording Absence & Date (17) Signature of Supervisor & Date Notified Wed Thur Official Action on Application Fri (18)  Approved  Disapproved (Give Reason) (19) Signature if Supervisor & Date Sat 20)  Approved  Disapproved (Give Reason) (21) Signature if Commissioner & Date Warning: The Furnishing of false information on the form may result in Criminal Action under V.I. Criminal Status: GPO Form 3971, May 1995 During This Absence, I was Incapacitated for Duty By:  Sickness  Caring for Patient (or)  On The Job Injury Exposed to A  Off The Job Injury Contagious Disease  Pregnancy or/&  Undergoing Medical  Confinement Denial or Optical Examination or Treatment CERTIFICATE OF PHYSICIAN OF PRACTITIONER I certify that ______________________has been under my Professional care and that he/she was incapacitated for work from ____________________________, 20____________ (Month and Day) thru _____________________________, 20____________ (Month and Day) ________________________ ______________ (Signature) (Date) _________________________________________ (Name) _________________________________________ (Address) ________________________________________________ REMARKS: Scheduled Unscheduled PP # Fiscal Year Day Init. Hours Sun Mon Tues Wed Privacy Act: This information will be used to grant or deny your request for official leave from V.I. Government service duty. As a routine use, this information may be disclosed to an appropriate law enforcement agency for investigative or prosecutorial proceedings, to any agency where relevant to hiring, contracting or licensing, to a labor organization as may be required, to the Equal Employment Opportunity Commission for investigation of an EEO complaint, and where pertinent. In a legal proceedings to which the V.I. Government is a party. Completion of this form is voluntary. However, if this information is not provided, official leave may not be granted. Thur Fri Sat Sun Mon Tue Wed Thur Fri