State Of West Virginia Application For Leave With Pay
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1STATE OF WEST VIRGINIA
APPLICATION FOR LEAVE WITH PAY
NAME:
WORK UNIT/SECTION:
DIVISION:
I AM MAKING APPLICATION FOR THE FOLLOWING LEAVE WITH PAY:
_______ Hours Annual
_______ Hours Sick
_______ Hours Annual (exhaustion of SL)
_______ Hours Sick (Imm. Family)
_______ Hours Military
_______ Hours Sick (Death in Imm. Family)
_______ Hours Witness/Jury Service
_______ Hours Grievance Prep/Hearing
PERIOD OF LEAVE:
FROM
Date: _____________________________
___________
X A.M. X P.M.
TO
Date: _____________________________
___________
X A.M. X P.M.
EMPLOYEE SIGNATURE:
APPLICATION DATE:
G Approved
IMMEDIATE SUPERVISOR SIGNATURE and DATE:
G Disapproved
_________________________________
________________
G Approved
AGENCY-AUTHORIZED SIGNATURE and DATE:
G Disapproved
_________________________________
________________
REMARKS (In addition to an y pertinent remarks, please also use this space to note relationship if using sick leave
for a family member’s illness, dental/medical appointment, or death):
• A Physician's/Practitioner’s Statement DOP-L3 is required after 3 consecutive working days of sick
leave.
• Sick leave used for immediate family members is limited to 40 hours per calendar year.
• A maximum of 3 days of sick leave may be used for each occurrence of a death in the employee's
immediate family.
• When witness/jury service leave or military leave is used, you must submit copies of the appropriate
subpoena, summons, or military orders, according to Division of Personnel rules and policies.
• Do NOT use this form for requesting paid (sick or annual) leave under the federal Family and
Medical Leave Act. Instead, use forms DOP-L3 through DOP-L8 (as applicable).
FORM DOP-L1
Pag e 1 of 1
07/21/11
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