Phs 1345 Form – Fill Out and Use This PDF

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		GRADE	SSN	TYPE OF LEAVE REQUESTED
				ANNUAL	STATION	SICK
DUTY STATION (Organization and Address)			PHS NO.
				OTHER (Explain in Remarks)

								PERIOD OF ABSENCE
					NO. DAYS			FROM (m/d/y)	THROUGH (m/d/y)
PHONE No. including Area Code (		)
ADDRESS (Where officer can be contacted during leave period)					REMARKS
PHONE No. including Area Code (		)
I have read and understand the information contained on the back of this form.
SIGNATURE										DATE
2. TO BE COMPLETED BY SUPERVISOR
RECOMMENDATION		SIGNATURE					TITLE			DATE
APPROVED
DISAPPROVED
3. TO BE COMPLETED BY LEAVE GRANTING AUTHORITY
ACTION		SIGNATURE					TITLE			DATE
APPROVED
DISAPPROVED
4. TO BE COMPLETED BY OFFICER AND LEAVE GRANTING AUTHORITY UPON RETURN FROM LEAVE
TYPE OF LEAVE TAKEN	NO. DAYS		FROM	THROUGH		SIGNATURE (Officer)				DATE

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