Domestic Violence Leave Request form

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FLORIDA GULF COAST UNIVERSITY
- Domestic Violence Leave Request/Reporting Form
Florida Law requires the University to allow employees to take three (3) working days of leave within a 12month period if the employee or a family or household member is the victim of domestic violence and if the
leave is sought for specific reasons related to the domestic violence. Please refer to the Domestic Violence
Leave policy located at http://www.fgcu.edu/HR/policies.html for additional information. This completed form
must be submitted to Human Resources in advance except in cases of imminent danger.
Employee Name:
Univ. ID #.
Department Name:
Date(s) of Leave:
From:
To:
I will return to work on:
Explanation of Leave:
Note: Appropriate documentation may be requested by the Human Resources Department.
The information provided on this form is confidential and will not be communicated to my department,
however, it is my responsibility to notify my supervisor of my absence. I may refer him/her to Human
Resources for any questions related to the University’s policy on Domestic Violence Leave.
I affirm my intention to return to work as specified above and I understand that if I fail to comply with the terms
of this leave of absence, my employment may be terminated.
Employee Signature
Copy to:
Date
Human Resources – this form will be retained separate from the employee’s official personnel file and is
exempt from public records disclosure requirements until one year after the leave is taken.
Employee
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