Family and Domestic Violence Leave Request Form Template

FAMILY AND DOMESTIC VIOLENCE LEAVE REQUEST FORM

Section 1: Employee Details

Employee Name: [First Name] [Last Name]

Job Title: [Job Title]

Employee ID: [Employee ID Number]

Date of Request: [DD/MM/YYYY]

Section 2: Leave Details

I am requesting leave to deal with family and domestic violence.

Start Date of Leave: [DD/MM/YYYY]

End Date of Leave: [DD/MM/YYYY]

Total Hours/Days Requested: [Number] [Hours/Days]

I understand I am entitled to:

• Paid Leave (Full-time/Part-time)
• Unpaid Leave (Casual)

Section 3: Reason for Leave (Brief Description)

You do not need to provide specific details of the violence. Please state what you need the time for.

[Reason, e.g. Attending court appointment / Seeking medical attention / Relocating to safe housing / Arranging childcare]

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: [Please specify]

Evidence attached: [Yes/No]

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: __________________________

Date: __________________________

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Section 6: Employer / Manager Approval

Received Date: [DD/MM/YYYY]

Evidence Reviewed: [Yes/No]

Is the evidence sufficient? [Yes/No]

Leave Approved: [Yes/No]

If No, Reason: [Reason]

Manager Name: [Manager Name]

Manager Signature: __________________________

Date: __________________________

For Payroll Use Only:

• Date Processed: [DD/MM/YYYY]
• Pay Cycle: [Pay Cycle Name]