Family and Domestic Violence Leave Request Form Example
Example document for Family and Domestic Violence Leave Request Form. Use this as a reference when creating your own.
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Document: Family and Domestic Violence Leave Request Form
Example Document
Last updated 7/30/2026
FAMILY AND DOMESTIC VIOLENCE LEAVE REQUEST FORM
Section 1: Employee Details
Employee Name: Sarah Jenkins
Job Title: Senior Accountant
Employee ID: 10455
Date of Request: 15/10/2023
Section 2: Leave Details
I am requesting leave to deal with family and domestic violence.
Start Date of Leave: 16/10/2023
End Date of Leave: 16/10/2023
Total Hours/Days Requested: 1 Day (7.6 Hours)
I understand I am entitled to:
- Paid Leave (Full-time/Part-time)
- Unpaid Leave (Casual)
Section 3: Reason for Leave (Brief Description)
Attending court hearing for final intervention order.
Section 4: Evidence
I am providing the following evidence to support my request:
- Statutory Declaration
- Court Order (e.g. Intervention Order)
- Medical Certificate
- Police Report/Reference Number
- Other:
Evidence attached: Yes
Section 5: Declaration
I declare that:
- I am taking this leave because I am experiencing family and domestic violence.
- I need to take this leave to deal with the impact of the violence and to arrange for my safety or the safety of a relevant family member.
- The information I have provided is true and correct.
Employee Signature: S. Jenkins
Date: 15/10/2023
Section 6: Employer / Manager Approval
Received Date: 15/10/2023
Evidence Reviewed: Yes
Is the evidence sufficient? Yes
Leave Approved: Yes
If No, Reason: N/A
Manager Name: David Smith
Manager Signature: D. Smith
Date: 15/10/2023
For Payroll Use Only:
- Date Processed: 16/10/2023
- Pay Cycle: October Fortnightly 2
Notes
Notes:
- Sarah has chosen to use a Statutory Declaration as evidence, which is valid and satisfies the reasonable person test.
- She has kept the reason brief ('Attending court hearing') without disclosing personal details of the violence.
- The form was reviewed and approved quickly to ensure Sarah could attend her appointment without stress.
- The manager ensured the form was filed securely in Sarah's confidential personnel file, not in the general leave folder.
About this Example
Part of the Family and Domestic Violence Leave Request Form document collection
Document Type
Family and Domestic Violence Leave Request Form
A standard form for employees to formally request paid leave to deal with family and domestic violence situations.