Sample Medical Certificate Requirement Letter

Lucy Lee
Secretary
Department

Dear Ms. Lee:

On _____________ you received a written warning regarding your use of sick leave. Regrettably, these efforts have not brought about an improvement in your attendance.

Attendance records now indicate that since ________________ you have used a total of ____ days on ____ separate occasions, with the most recent period from _____ to _____ showing days and ______ occasions. Therefore, your attendance is still considered UNSATISFACTORY for the year, and for the quarter.

Because your attendance has not improved and you continue to make excessive use of sick leave, this letter shall serve as notice that you have been placed on a medical certificate requirement for each occasion of absenteeism. This form must be returned to the Department of Human Resources/Leave Administrator before you return to work in order to permit the utilization of accrued sick leave. Failure to send in an acceptable medical certificate when you return will result in you being docked pay for the day, and your time card will show a “0” (zero time).

A copy of this letter shall be placed in your personnel file. Due to your continual excessive use of sick leave, you may receive a rate of UNSATISFACTORY in attendance on your next performance appraisal. This could result in denial of your annual increment. This is a serious matter that needs to be attended to immediately.

We will continue our quarterly review and in nine (9) months a determination will be made, whether or not the medical certificate requirement should be rescinded. Every effort should be made to improve your attendance. Please do not hesitate to talk with me if I can be of assistance in any way.

Sincerely,

Supervisor

I have received the original of this letter:

___________________________________________
Employee or Representative’s Signature

___________________
Date

cc: Personnel File
Labor Relations
Department File
Vicki Fry