Sample - Continuous Absence - Exhaustion Of Paid Leave - No Communication (Page 2 of 4) in pdf

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

Physician’s/Practitioner’s Statement



[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

Sample - Continuous Absence - Exhaustion Of Paid Leave - No Communication Page 2