Crime-Victim and Witness Court-Attendance Leave Request Packet

EMPLOYER-NOTIFICATION AND PROSECUTION-COOPERATION PACKET

Kentucky — Ky. Rev. Stat. § 421.500(8)

This is an employer-notification assistance request, not a mandatory-leave notice. Use it for a victim or witness seeking help coordinating prosecution cooperation with an employer.

1. EMPLOYEE AND EMPLOYER

2. VICTIM OR WITNESS GATE

• ☐ Victim status under section 421.500 confirmed
• ☐ Witness status confirmed
• ☐ Cooperation in the prosecution may necessitate absence from work
• ☐ The employee requests assistance informing the employer

Confirmation by law enforcement, the Commonwealth's attorney, a victim advocate, counsel, or court personnel: [________________________________]

Do not include offense narratives, medical details, victim addresses, or other unnecessary information in this packet.

3. PROSECUTION-COOPERATION INFORMATION

Law-enforcement agency or Commonwealth's attorney's office: [________________________________]

Court, if an appearance is scheduled: [________________________________]

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

Cooperation date and time: [________________________________]

Expected work absence: [DATE / START / END]

• ☐ Subpoena or notice securely presented, if issued
• ☐ Scheduling confirmation securely presented
• ☐ Cancellation or continuance updates requested

4. REQUEST FOR EMPLOYER-NOTIFICATION ASSISTANCE

I request assistance under section 421.500(8) informing my employer that my cooperation in the prosecution may necessitate absence from work.

Requested limited contact:

• ☐ Explain the prosecution-cooperation need to the employer
• ☐ Confirm the date and expected duration
• ☐ Request a schedule adjustment
• ☐ Request consideration of available paid leave
• ☐ Request consideration of unpaid time
• ☐ Request treatment under an applicable policy or agreement
• ☐ Provide an update if the cooperation event is canceled or continued
• ☐ Other limited coordination: [________________________________]

Employee authorizes the following agency or office to contact the employer for this limited purpose: [________________________________]

Employee signature: __________________________ Date: ______________

5. ASSISTANCE RECORD

The assisting agency or office should disclose only the information needed for workplace coordination and should not represent section 421.500(8) as a mandatory leave or pay statute.

Assisting representative: ____________________ Date: ______________

6. EMPLOYER COORDINATION RESPONSE

• ☐ Absence approved under policy, agreement, or another law
• ☐ Schedule adjusted
• ☐ Paid leave available: [TYPE / HOURS]
• ☐ Unpaid time available: [HOURS]
• ☐ Benefit treatment: [________________________________]
• ☐ Additional minimally necessary confirmation requested
• ☐ Counsel review required

Employer representative: _____________________ Date: ______________

Response delivered to employee and assisting office: [DATE / METHOD]

7. CHANGE LOG

OFFICIAL SOURCE VERIFIED

• Kentucky General Assembly — Ky. Rev. Stat. § 421.500