Crime-Victim and Witness Court-Attendance Leave Request Packet

VESSA LEGAL-PROCEEDING LEAVE REQUEST PACKET

Illinois — 820 ILCS 180/20

Use this packet only for a covered violence-related purpose, including seeking legal assistance or remedies or preparing for or participating in a related civil, criminal, or military legal proceeding.

1. EMPLOYEE AND EMPLOYER

2. COVERED-PERSON AND VIOLENCE GATE

The covered person is:

• ☐ The employee
• ☐ A family or household member whose interests are not adverse to the employee regarding the violence

The covered person is a victim of:

• ☐ Domestic violence
• ☐ Sexual violence
• ☐ Gender violence
• ☐ Another crime of violence

Relationship, if applicable: [________________________________]

Coverage confirmed through counsel, an advocate, a victim-services organization, law enforcement, court personnel, or another appropriate source: [________________________________]

Do not include an offense narrative, protected address, medical details, or other unnecessary information.

3. COVERED LEGAL-PROCEEDING PURPOSE

The employee requests leave to address the covered violence by:

• ☐ Seeking legal assistance or remedies to ensure the health and safety of the employee or qualifying family or household member
• ☐ Preparing for a related civil legal proceeding
• ☐ Participating in a related civil legal proceeding
• ☐ Preparing for a related criminal legal proceeding
• ☐ Participating in a related criminal legal proceeding
• ☐ Preparing for a related military legal proceeding
• ☐ Participating in a related military legal proceeding

Court, agency, counsel, or proceeding: [________________________________]

Case identifier, using the minimum necessary information: [________________________________]

Proceeding or preparation date and time: [________________________________]

Expected work absence: [DATE / START / END]

4. LEAVE AMOUNT AND SCHEDULE

Employer size determines the total VESSA leave available during a 12-month period, subject to statutory coordination and exceptions:

• ☐ 50 or more employees — up to 12 workweeks
• ☐ 15 through 49 employees — up to 8 workweeks
• ☐ 1 through 14 employees — up to 4 workweeks

Requested schedule:

• ☐ Consecutive leave: [START / END]
• ☐ Intermittent leave: [DATES / BLOCKS]
• ☐ Reduced work schedule: [HOURS / DAYS]

VESSA leave for this route is unpaid. Record any separate paid-leave treatment available under an employer policy, agreement, or other law without reducing the statutory protection:

• ☐ Unpaid leave requested
• ☐ Available paid leave requested under another policy or law: [TYPE / HOURS]

VESSA does not create unpaid leave exceeding or additional to unpaid leave permitted by the federal Family and Medical Leave Act. Obtain counsel review when another leave law covers the same absence.

5. NOTICE

The employee should provide at least 48 hours' advance notice unless doing so is not practicable.

• ☐ At least 48 hours' advance notice delivered
• ☐ Advance notice was not practicable
• ☐ Unscheduled absence occurred; employer-requested certification will be supplied within a reasonable period

Notice date, method, and recipient: [________________________________]

Employee or designee: _________________________ Date: ______________

6. CERTIFICATION, IF REQUESTED

If the employer requests certification, the employee may satisfy the request with a sworn employee statement and, if the employee possesses one, one employee-selected supporting document.

• ☐ Sworn employee statement securely provided
• ☐ Victim-services, attorney, clergy, medical, or other professional documentation
• ☐ Police record
• ☐ Court record
• ☐ Military record
• ☐ Other corroborating evidence
• ☐ Employee possesses no supporting document

Certification delivered within a reasonable period after request: [DATE / METHOD]

The employee chooses the supporting document. For leave related to the same incident or incidents, or the same perpetrator or perpetrators, the employer may not request or require more than one document during the same 12-month period in which leave is requested or taken.

7. CONFIDENTIALITY AND EMPLOYER RESPONSE

The employer must retain in the strictest confidence the notice, certification, supporting material, and the fact that the employee requested or obtained leave, except when the employee requests or consents to disclosure in writing or applicable federal or State law requires disclosure.

• ☐ Covered-person and violence gate confirmed
• ☐ Covered legal-proceeding purpose confirmed
• ☐ Employer-size leave tier confirmed
• ☐ Notice or impracticability route confirmed
• ☐ Certification received or calendared
• ☐ Consecutive, intermittent, or reduced schedule recorded
• ☐ Leave approved as requested
• ☐ Pay / leave-bank treatment recorded: [________________________________]
• ☐ Strict confidential-storage and access controls applied
• ☐ Counsel review required

Employer representative: _____________________ Date: ______________

8. RETURN, BENEFITS, AND NONRETALIATION

• ☐ Return to the same position recorded
• ☐ Return to an equivalent position with equivalent benefits, pay, and terms recorded
• ☐ Employment benefits accrued before leave preserved
• ☐ Health-plan coverage maintained on the statutory terms
• ☐ No interference, restraint, denial, discrimination, or retaliation because of protected rights or participation in a protected proceeding or inquiry

9. CHANGE LOG

OFFICIAL SOURCE VERIFIED

• Illinois General Assembly — 820 ILCS 180/20