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Get PHS-1345 2005-2021

ME GRADE SSN TYPE OF LEAVE REQUESTED ANNUAL DUTY STATION (Organization and Address) PHS NO. STATION SICK OTHER (Explain in Remarks) PERIOD OF ABSENCE NO. DAYS PHONE No. including Area Code ( FROM (m/d/y) THROUGH (m/d/y) ) REMARKS ADDRESS (Where officer can be contacted during leave period) 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 TIT.

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