NAME:
HOME ADDRESS:
SOCIAL SECURITY NUMBER:
DATES/HOURS OF ADMINISTRATIVE LEAVE REQUESTED:
POSTAL FACILITY:
TYPE OF TRANSPORTATION USED:
DESCRIBE ROUTE TO WORK:
TIME YOU REGULARLY LEAVE FOR WORK:
DID YOU ATTEMPT TO REPORT TO WORK? YES NO
TIME YOU LEFT FOR WORK ON DAY(S) IN QUESTIONS:
WEATHER CONDITIONS AT YOU HOME WHEN YOU LEFT FOR WORK:
WERE YOU ABLE TO REPORT TO WORK?
WHAT ROUTES DID YOU TAKE TO GET TO WORK?
DESCRIBE IN DETAIL WHAT EFFORT(S) YOU MADE TO REPORT TO WORK:
DESCRIBE WHAT DIFFICULTIES, IF ANY, YOU ENCOUNTERED WHEN ATTEMPTING TO REPORT TO WORK:
WHAT OBSTACLES WERE THERE, IF ANY (SUCH AS BLOCKED HIGHWAYS, BRIDGES, CONSTRUCTION, HILLS, ETC) THAT HAMPERED YOUR ABILITY TO REPORT TO WORK:
DID YOU MAKE ANY SUBSEQUENT EFFORTS TO REPORT TO WORK? YES NO
IF YES, EXPLAIN:
IF NOT, WHY NOT?
ADDITIONAL COMMENTS:
SIGNATURE________________________________________________________
DATE______________________________
December 19, 2000
