- The following sample memorandum of instruction was prepared to primarily address a problem connected with improper use or request for sick leave. It would need to be adapted somewhat to apply to other attendance related situations, such as lack of advance request for annual leave, tardiness or long lunches.
- If the employee is in a bargaining unit, the collective bargaining agreement should be consulted for any provisions that impact the issuance of such a memorandum. It is not uncommon for a contract to contain a requirement that an employee receive counseling prior to being placed on a memorandum/letter
MEMORANDUM FOR (Employee's name, title and organization)
SUBJECT: Memorandum of Instruction
This memorandum is being issued to remind you of the established leave policy of this organization and to define additional administrative requirements
regarding your use of leave. This is necessary because of your excessive use of unscheduled sick (annual) leave (without pay).
You have been previously counseled (should give date or dates of the counseling sessions) that your attendance record was unsatisfactory and that if
improvement was not made other administrative remedies available would be pursued in order to assist you in improving your attendance. You were also advised of the agency rules governing leave usage and the specific requirements which you would have to follow for future absences. Since that time, your attendance record has remained unacceptable. Accordingly, you are now advised of specific requirements, applicable to you, for the next twelve months commencing with the date you recieved of this memorandum.
According to policy, annual leave is to be scheduled, requested, and approved in advance. Except for emergencies, all annual leave must be scheduled at
least ___ days/weeks in advance of its intended use by completing Standard Form(SF)71 (Application for Leave)(or other locally used form).
Annual leave will only be approved when the mission of this organization is not adversely affected. This policy applies to all employees.
Emergency Annual/Sick Leave
If an emergency situation arises in which you are prevented from reporting to work, you are to notify me not later than __ hours on that date. If I am not
available, you are to talk with ___________ or, in his/her absence, __________. You are cautioned that a determination will be made as to the appropriateness of
your request for emergency leave use, and leave will be approved only for those reasons deemed to be legitimate emergencies. If I do not approve it, you will be
expected to be at work within ____ minutes. If you fail to arrive by that time, you will be charged as absent without leave (AWOL) and appropriate disciplinary action will be considered.
Leave for Medical Reasons
In the event of illness, you must call me no later than _____ on the first day of your absence and advise me of the expected duration of your absence. If you are unable to return to work on the date indicated, you must contact me by ____ on that date to further advise me of your continued absence. It is not acceptable to have a relative or friend call for you. I must know of your incapacitation and it's expected duration so that work accomplishment can be planned accordingly.
In addition, for all absences for medical reasons, I am requiring you to furnish a physician's or other licensed medical practitioner's statement certifying to the incapacitation for duty, examination, or treatment for the period of your absence. You are required to complete the front of a SF-71 (Application for Leave) (or specify another form used locally), and have the physician or practitioner complete and sign the reverse of the form or attach a letter or note, provided that it bears the letterhead of the physician or medical care provider as well as his/her original signature. This medical statement is required for each absence of one hour or more.
(Note: if you record sick and annual leave in less than 1 hour increments, indicate the lesser amount, e.g., fifteen minutes), regardless of whether you request sick leave, annual leave, or leave with or without pay for medical reasons.
Failure to provide the physician's statement within three workdays following your return to work will result in a charge of absence-without-leave (AWOL) for
the time of your absence, and appropriate disciplinary action will be considered for being AWOL and for failure to follow prescribed leave procedures.
This leave requirements memorandum will remain in effect for 1 year. I will review your leave usage at that time and decide at that time whether to continue
these additional requirements.
As a Federal employee, you are responsible for performing the official duties of your position and for conducting yourself in an appropriate manner. You are expected to report to work ready, willing and able to perform the duties of your position. I am available to discuss this memorandum or to answer questions you may have about leave procedures. The primary responsibility for improvement rests with you. I emphasize that failure to comply with the provisions set forth in this memorandum may result in formal disciplinary action.
(Optional) If you are experiencing problems that prevent you from coming to work on a regular basis and need help to correct them, you may want to contact the _______ (appropriate Employee Assistance Office). This office exists to provide counseling assistance to employees who have problems that impact on their performance and conduct while on the job, including problems associated with attendance and the use of leave. Their telephone number is ________. You may wish to telephone that office to make an appointment. The counseling service is confidential and no information can be released to me without your written
I am willing to approve a limited amount of official time for an initial visit with that office. You must request this time from me in advance and inform me of the date and time of any appointment with that office.
Please acknowledge receipt of this memorandum by signing the record copy provided. Failure to sign will not void the content of this memorandum.
Signature Block of Supervisor
Give original to employee, have employee sign an acknowledgment on a copy with the supervisor's signature. Send acknowledgment and an extra copy to CPAC advisor. A sample acknowledgment is:
Received by _________________________ Date______
Should the employee decline to sign, you should so indicate, sign, and date.
Notice: Always coordinate with the CPAC before issuing this notice!