<table style="width:100%;">
<colgroup>
<col style="width: 14%" />
<col style="width: 5%" />
<col style="width: 3%" />
<col style="width: 12%" />
<col style="width: 5%" />
<col style="width: 7%" />
<col style="width: 2%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 11%" />
<col style="width: 7%" />
<col style="width: 4%" />
<col style="width: 14%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="13"><p><strong>DEPARTMENT OF HEALTH AND HUMAN
SERVICES</strong></p>
<p><strong>PUBLIC HEALTH SERVICE COMMISSIONED CORPS</strong></p>
<p><strong>REQUEST AND AUTHORITY FOR LEAVE OF ABSENCE (Commissioned
Officers)</strong></p></td>
</tr>
<tr class="even">
<td colspan="13">1. TO BE COMPLETED BY THE OFFICER <em>(Type or
Print)</em></td>
</tr>
<tr class="odd">
<td colspan="5"><p>NAME</p>
<p>     </p></td>
<td colspan="2" rowspan="2"><p>GRADE</p>
<p>     </p></td>
<td colspan="3"><p>SSN</p>
<p>     </p></td>
<td colspan="3" rowspan="2"><p>TYPE OF LEAVE REQUESTED</p>
<p> ANNUAL STATION SICK</p>
<p> OTHER <em>(Explain in Remarks)</em></p></td>
</tr>
<tr class="even">
<td colspan="5" rowspan="3"><p>DUTY STATION <em>(Organization and
Address)</em></p>
<p>     </p></td>
<td colspan="3"><p>PHS NO.</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="8">PERIOD OF ABSENCE</td>
</tr>
<tr class="even">
<td colspan="4" rowspan="2"><p>NO. DAYS</p>
<p>    </p></td>
<td colspan="2" rowspan="2"><p>FROM (m/d/y)</p>
<p>     </p></td>
<td colspan="2" rowspan="2"><p>THROUGH (m/d/y)</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="5"></td>
</tr>
<tr class="even">
<td colspan="5"><p>ADDRESS <em>(Where officer can be contacted during
leave period)</em></p>
<p>     </p></td>
<td colspan="8" rowspan="2"><p>REMARKS</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="5">PHONE No. including Area Code (     )      </td>
</tr>
<tr class="even">
<td colspan="13">I have read and understand the information contained on
the back of this form.</td>
</tr>
<tr class="odd">
<td colspan="12">SIGNATURE</td>
<td>DATE</td>
</tr>
<tr class="even">
<td colspan="13">2. TO BE COMPLETED BY SUPERVISOR</td>
</tr>
<tr class="odd">
<td colspan="2"><p>RECOMMENDATION</p>
<blockquote>
<p>APPROVED</p>
<p>DISAPPROVED</p>
</blockquote></td>
<td colspan="6">SIGNATURE</td>
<td colspan="4"><p>TITLE</p>
<p>     </p></td>
<td>DATE</td>
</tr>
<tr class="even">
<td colspan="13">3. TO BE COMPLETED BY LEAVE GRANTING AUTHORITY</td>
</tr>
<tr class="odd">
<td colspan="2"><p>ACTION</p>
<blockquote>
<p>APPROVED</p>
<p>DISAPPROVED</p>
</blockquote></td>
<td colspan="6">SIGNATURE</td>
<td colspan="4"><p>TITLE</p>
<p>     </p></td>
<td>DATE</td>
</tr>
<tr class="even">
<td colspan="13">4. TO BE COMPLETED BY OFFICER AND LEAVE GRANTING
AUTHORITY UPON RETURN FROM LEAVE</td>
</tr>
<tr class="odd">
<td>TYPE OF LEAVE TAKEN</td>
<td colspan="2">NO. DAYS</td>
<td>FROM</td>
<td colspan="2">THROUGH</td>
<td colspan="6">SIGNATURE <em>(Officer)</em></td>
<td>DATE</td>
</tr>
<tr class="even">
<td colspan="4">SIGNATURE <em>(Leave Granting Authority)</em></td>
<td colspan="2">DATE</td>
<td colspan="7"></td>
</tr>
</tbody>
</table>

PHS-1345 (Rev. 9/05) FRONT (See Privacy Act Statement on Back) PSC Media
Arts (301) 443-1090 EF

**DEPARTMENT OF HEALTH AND HUMAN SERVICES\
PUBLIC HEALTH SERVICE COMMISSIONED CORPS**

**COMMISSIONED CORPS LEAVE OTHER THAN SICK LEAVE**

1\. Authority: 42 U.S.C. 210-1. See also INSTRUCTIONs 1 and 2,
Subchapter CC29.1, of the Commissioned Corps Personnel Manual (CCPM).

2\. The original copy of this form must be kept in the officer's
possession at all times while he/she is in leave status.

3\. The number of days of annual leave used is computed by counting each
calendar day taken during the period of leave, including nonwork days
and\
holidays.

4\. Public Health Service (PHS) commissioned officers are eligible for
medical care at all Uniformed Services facilities and for emergency care
at\
Department of Veterans Affairs hospitals, other Federal non-uniformed
services hospitals, and civilian medical care facilities. An officer who
requires\
non-PHS medical care while in leave status must report such care
immediately to the PHS Service Point of Contact (SPOC), Medical Affairs
Branch, at\
1-800-368-2777, option 2.

5\. An officer in leave status must report changes in his/her
whereabouts to the leave granting authority.

6\. Immediately upon return to duty, the officer must complete Section 4
of the original copy of the form, obtain the leave granting authority's
verification\
signature, and return the form to the leave maintenance clerk. The
officer should retain a copy of this form for his/her records.

**COMMISSIONED CORPS SICK LEAVE**

1\. An officer who becomes ill while on annual leave must notify the
leave granting authority of his/her illness and request sick leave.
He/she must also\
report the termination of sick leave status.

2\. Sick leave must be reported on this form as stated in INSTRUCTION 4,
Subchapter CC29.1, of the CCPM.

3\. Immediately upon return to duty, the officer must complete Section 1
and/or 4 (as appropriate) of the original copy of this form and obtain
the leave\
granting authority's verification signature. The leave granting
authority must send the completed original of this form to PSC/OCCSS,
ATTN: Medical Affairs Branch, Room 4C-04, 5600 Fishers Lane, Rockville,
MD 20857-0001.

Privacy Act Notice PHS-1345\
\"Request and Authority for Leave of Absence (Commissioned Officers)\"

This statement is provided pursuant to the Privacy Act of 1974 (5 U.S.C.
552a). Our authority to collect this information is 42 U.S.C. 202 et
seq.; and\
Executive Order 9397, \"Numbering System for Federal Accounts Relating
to Individuals Persons.\"\
\
The information provided on this form will become part of record systems
09-40-0001, \"PHS Commissioned Corps General Personnel Records,\"\
HHS/PSC/HRS; 09-40-0002, \"PHS Commissioned Corps Medical Records,
\"HHS/PSC/HRS, or 09-40-0010, \"Pay, Leave and Attendance Records,\"\
HHS/PSC/HRS. Copies of these systems of records may be obtained by
contacting the Office of Commissioned Corps Operations, ATTN: System\
Manager, Suite 100, 1101 Wootton Parkway, Rockville, MD 20852.

This information is used to request approval of annual or sick leave.
This information will be used only as necessary in personnel
administration processes\
carried out in accordance with established regulations and published
notices of systems of records.

**Effects of Nondisclosure:**

Completion of this form is mandatory. Failure to provide the information
will result in non-approval of leave and an officer being charged with
Absence\
Without Authorized Leave (AWOL). This in turn may result in forfeiture
of pay and separation from the Service. Furthermore, failure to
officially record\
absences due to illness or injury will undetermine the health
maintenance activity of the commissioned corps and may result in
inadequate documentation\
for future medical benefits determination.

Disclosure of the Social Security Number (SSN) is mandatory under
provisions of Executive Order 9397 to obtain benefits and services as a
commissioned\
officer inasmuch as the SSN is used to distinguish a record from those
of commissioned officers who may have similar names and dates of birth.
All\
statements are subject to verification.

PHS-1345

(Rev. 9/05) BACK