Understanding the complexities of taking a leave of absence in the Department of Health and Human Services, Public Health Service Commissioned Corps, is streamlined with the PHS 1345 form. This form serves as the formal request and authority document for leave of absence for commissioned officers, emphasizing the stringent process for approval and documentation. The information required from the officer includes basic identification, type of leave requested, along with the duration and specifics of the leave period. This form not only aids in the efficient management of leave requests but also ensures that officers are knowledgeable about the procedures and responsibilities during their absence. Supervisors and leave granting authorities play crucial roles in the process, marking their recommendations and approvals on the document, which upholds the integrity of the leave system. Moreover, the form outlines clear instructions for situations like sickness during annual leave and the necessity of reporting such instances to maintain accurate medical records and leave status. The importance of compliance with these procedures is underscored by the fact that failure to properly request and document leave can lead to serious consequences, including being marked as Absence Without Authorized Leave (AWOL), potential forfeiture of pay, or even separation from service. The form also serves a critical role in ensuring the health and well-being of commissioned officers are adequately documented and communicated, facilitating access to necessary medical care, and safeguarding future benefits.
| Question | Answer |
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| Form Name | Phs 1345 Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | phs 1345, usphs 1345, commissioned officers rev, 1345 request statement |
DEPARTMENT OF HEALTH AND HUMAN SERVICES
PUBLIC HEALTH SERVICE COMMISSIONED CORPS
REQUEST AND AUTHORITY FOR LEAVE OF ABSENCE (Commissioned Officers)
1. TO BE COMPLETED BY THE OFFICER (Type or Print)
NAME |
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SSN |
TYPE OF LEAVE REQUESTED |
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ANNUAL |
STATION |
SICK |
DUTY STATION (Organization and Address) |
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PHS NO. |
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OTHER (Explain in Remarks) |
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PERIOD OF ABSENCE |
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NO. DAYS |
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FROM (m/d/y) |
THROUGH (m/d/y) |
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PHONE No. including Area Code ( |
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ADDRESS (Where officer can be contacted during leave period) |
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REMARKS |
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PHONE No. including Area Code ( |
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I have read and understand the information contained on the back of this form. |
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SIGNATURE |
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DATE |
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2. TO BE COMPLETED BY SUPERVISOR |
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RECOMMENDATION |
SIGNATURE |
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TITLE |
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DATE |
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APPROVED |
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DISAPPROVED |
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3. TO BE COMPLETED BY LEAVE GRANTING AUTHORITY |
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ACTION |
SIGNATURE |
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TITLE |
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DATE |
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APPROVED |
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DISAPPROVED |
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4. TO BE COMPLETED BY OFFICER AND LEAVE GRANTING AUTHORITY UPON RETURN FROM LEAVE |
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TYPE OF LEAVE TAKEN |
NO. DAYS |
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FROM |
THROUGH |
SIGNATURE (Officer) |
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DATE |
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SIGNATURE (Leave Granting Authority)
DATE
(See Privacy Act Statement on Back) |
PSC MEDIA ARTS (301) |
DEPARTMENT OF HEALTH AND HUMAN SERVICES
PUBLIC HEALTH SERVICE COMMISSIONED CORPS
COMMISSIONED CORPS LEAVE OTHER THAN SICK LEAVE
1.Authority: 42 U.S.C.
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
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
Privacy Act Notice
"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
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
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.
(Rev. 9/05) BACK