Legend and suggested codes
A black square marks the last day of each month and H marks a holiday. The suggested codes are A for Annual Leave, S for Sick Leave, E for Excused, W for Absent Without Leave, M for Military Leave, R for Restored Leave, D for Award Leave, L for Leave Without Pay, CE for Compensation Time Earned, CU for Compensation Time Used, OT for Overtime and C for Continuation of Pay for Traumatic, as printed.
Leave earned box
For leave categories 4, 6 and 8 the form prints annual leave earned per pay period of 1 hour per 20, 13 and 10 hours worked. For sick leave it says 1 hour is earned for each 20 worked, regardless of category.
Daily pay period grid
Rows for pay periods 2 to 26, from 1/1 - 1/14 to 12/3 - 12/16, then pay period 1, 12/17 - 12/30, and pay period 2 again, 12/31 - 1/13. Each row has 14 day boxes, Sunday to Saturday twice.
Annual leave and sick leave columns
Each section has a carryover box, leave hours and work hours, and per pay period columns for total hours worked, hours applied to leave earned, balance of hours worked, earned and used this pay period, used to date and balance.
Employee block and tour of duty
Address, last name, first name and middle initial, leave category code, block number, telephone number, service computation date, and the entered on or transmittal date. A tour of duty box sits at the top right.
Back page: other leave categories
Untitled columns for each pay period. The form lists examples such as Shared (Donated), Restored, Award, Family Friendly, Military, Compensatory Leave and Credit Hours, plus premium pay such as Night Differential and Overtime.