Sample Leave Restriction Letter

To: Employee Name, Title
From: Supervisor Name, Title
Subject: Leave Approval and Documentation (Leave Restriction)
The purpose of this letter is to inform you that for a period of [state the duration of the
restriction, often a year] from the date of this letter I am restricting your use of sick,
annual, and leave without pay. I am taking this action because of the recent pattern of
your use of leave. You are to adhere strictly to the following procedures and to
understand that I am the only person who can approve your leave requests. A violation
of these procedures will result in your being charged absent without leave (AWOL) and I
will formally discipline you.
[State a legitimate, work-related reason for issuing this letter. The following examples are provided to
illustrate several types of work-related problems that you have the authority to address. The
example(s) you list do not have to be as extensive and obvious as those listed below.]
With regard to your absenteeism, you have used 144 hours of annual leave and 222.5
hours of sick leave since May of 20 . Most of the annual leave was unanticipated,
i.e., used primarily for illness and not requested in advance. Your current annual leave
and sick leave balances are zero (0). In addition, I approved leave-without-pay (LWOP)
for 7 hours on June 2, 20 , and 8 hours on June 15, 20 because you did not have
sufficient leave to cover your recent absences due to illness. Your unanticipated
absences from work on annual leave, sick leave, and LWOP typically occur on Mondays
or Fridays, at two-week intervals.
With regard to your tardiness, you arrived at work between 20 and 25 minutes late on
the following dates: May 14, 15, 17, 20, and June 7, 8, 10, 11, 14, and 17, 20 . On
May 25, 20 you called in at 8:00 a.m. to request 2 hours of annual leave. On June 1,
9, 16, and 18, 20 , you called in after 8:00 a.m. to request annual leave so that you
could arrive late to work.
It is essential that you meet the standards of attendance necessary to do your job. This
office maintains a small staff relative to its work load, and I must be able to depend on
you to be present to carry out your duties. Your absenteeism and tardiness limits your
ability to effectively carry out your assignments and is negatively impacting the
efficiency of this office.
Annual leave: All requests for annual leave must be made in writing and submitted to
me at least two work days prior to the date you are asking that the leave begin. You are
to explain in detail the reason that you are requesting leave for this time. You are to
understand that your leave request is not approved until I respond to your request in
writing. Requests for annual leave that are not made at least two work days in advance
will be granted only in the most serious situations. In emergency situations in which you
unexpectedly are not able to report to work, you are to contact me by phone no later
than one hour after the beginning of your shift to request leave. I will not approve any
request for annual leave that are not made in advance until you satisfy me with
evidence that your absence was justified. My decision normally will not be made until
you return to work after the absence.
Sick leave: Requests for sick leave must be submitted to me in writing as far in
advance as reasonably possible. You are to explain in detail the reason that you are
requesting leave for this time. You are to understand that your leave request is not
approved until I respond to your request in writing. I will grant your request for sick leave
only if you present me with administratively acceptable evidence of the condition
warranting a grant of sick leave.
Requests for sick leave that are not made in advance in writing due to the onset of
illness or injury must be made to me at the first opportunity by you or someone acting
on your behalf if you are incapacitated, and may be done so orally. Such requests will
be made no later than within one hour of the beginning of your shift, except under the
most unusual circumstances. I will withhold my decision as to whether to grant such a
request until you provide me a medical certificate from your treating physician that
documents the illness or injury as follows:
1. The history of the medical condition including summaries of findings from

previous examinations, treatment, and responses to treatment;
2. Clinical findings from the most recent medical evaluation including any of the
following which have been obtained: results of physical examinations, laboratory
tests, x-rays, EKG's, and other diagnostic procedures;
3. Diagnosis;
4. Prognosis, including plans or recommendations for future treatment and an
estimate of the expected date of full or partial recovery; and
5. An explanation of how your medical condition impacts your overall health and
activities, including the basis for a conclusion that restrictions or accommodations
are warranted.
Provide your medical certification to me within one week of your return to duty.
Leave Without Pay: Except for those rare situations in which you might be entitled to
leave without pay by law, I will not approve and such requests during this leave
restriction period.
Advanced Leave: I will not grant you any type of advanced leave during this leave
restriction period.
Should you have any questions about this rule, you should direct them to me
immediately or as soon as possible if they arise in the future. Should you fail to abide by
the requirements of this letter, I will deny your leave request and take disciplinary action
against you, up to and including removal from service.
If you believe that personal, medical, or other problems are reasons for the problems
addressed in this memo, you may provide documentation of a medical condition or
discuss these problems with me. You may contact the Employee Assistance Program
at 1-800-222-0364 for assistance.
___________________________
[Supervisor's Signature]
Acknowledgement of receipt: _____________________ _______________
[Employee's Signature] [Date]

Sample Leave Restriction Letter

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Sample Leave Restriction Letter

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What restrictions are placed on the employee's leave?

What documentation is required for sick leave requests?

To: Employee Name, Title

From: Supervisor Name, Title

Subject: Leave Approval and Documentation (Leave Restriction)

1. The history of the medical condition including summaries of findings from

Acknowledgement of receipt: _______ _

[Employee's Signature] [Date]

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