used by your agency which are either the DOP prescribed forms or the forms your agency’s prescribed
forms has chosen which have been approved by the DOP]:
[DOP‐ Prescribed Forms]: Application for Leave of Absence Without Pay and
[Name of Agency Forms ‐ Approved by DOP]
You are a valued employee [if untrue, do not say.]; however, as it is our mission to provide timely
services to the public, I am obligated to ensure the overall efficiency of the agency by maintaining a full
work force. Your failure to report for work on [date], as scheduled, absent any information that
documents a serious illness, and your failure to maintain appropriate and timely communication with
your supervisor, compromises my ability to effectively plan, schedule, and assign work, which directly
impacts the mission of the agency.
I have been very tolerant of your situation and have attempted to assist you; however, I cannot tolerate
your failure to report for work as scheduled or to adhere to the procedures for requesting a medical
leave of absence without pay. You are, therefore, directed to either return to work on [date] at [time]
and report to me prior to beginning work, with a physician’s statement certifying your period of
incapacity and any limitations/restrictions on your ability to work, if applicable, or to request a leave of
absence without pay according to the Administrative Rule no later than [date – 15 calendar days from
the date of this letter].
[NOTE TO SUPERVISOR: If there has been previous communication with the employee and he or she
has been made aware of requirement to submit documentation, it is suggested that this letter be
modified to be a dismissal letter, without providing an opportunity to return.]
Should you fail to follow this directive, I will conclude you have abandoned your position, and in such
case, this letter will serve as notice of your dismissal from your position as a [classification] effective,
[date ‐ 15 calendar days from the date of the letter.].
In such case, all property belonging to the State of West Virginia, which you have under your control or
possession, should be returned either by mail to [name and address] or directly to [name], [title], by
close of business on [date] at a mutually agreed upon time and location. Such property shall include,
but not be limited to: keys to any State offices, access cards, and identification cards and any other
items of value such as cameras, computers, other information technology equipment, and State
vehicles. You are not to enter the non‐public areas of the [agency/department name] offices without
prior authorization from me or an agent of my office.
This personnel action would be taken in accordance with subsection 12.2.c. of the Administrative Rule,
and provides for a fifteen (15) calendar day notice period. Whereas you would be dismissed for job
abandonment you would be ineligible for severance pay. You would, however, be paid for all annual
leave accrued and unused as of your last working day.
You may respond to the matters of this letter, either in writing or in person, provided you do so within
fifteen (15) calendar days of the date of this letter. Please contact my office at [telephone number] if