Crime-Victim and Witness Court-Attendance Leave Request Packet

NJ SAFE ACT LEGAL-PROCEEDING LEAVE REQUEST PACKET

New Jersey — N.J.S.A. 34:11C-2 to -5

Use this packet only after confirming the employer, employee, victim-status, relationship, timing, and covered-purpose gates below.

1. EMPLOYEE AND EMPLOYER

2. EMPLOYER AND EMPLOYEE ELIGIBILITY

Employer gate:

• ☐ Employer had 25 or more employees for each working day during at least 20 calendar workweeks in the current or immediately preceding calendar year
• ☐ State or other covered public employer

Employee gate:

• ☐ Employee has been employed by this employer for at least 12 months
• ☐ Employee worked at least 1,000 base hours during the immediately preceding 12-month period

Coverage basis: [________________________________]

3. VICTIM AND RELATIONSHIP GATE

The employee or qualifying person was a victim of:

• ☐ An incident of domestic violence
• ☐ A sexually violent offense

The victim is:

• ☐ The employee
• ☐ Parent-in-law
• ☐ Sibling
• ☐ Grandparent
• ☐ Grandchild
• ☐ Child
• ☐ Parent
• ☐ Spouse
• ☐ Domestic partner
• ☐ Civil union partner
• ☐ Another person related by blood to the employee
• ☐ Another person with a close association equivalent to a family relationship

Relationship, if applicable: [________________________________]

Victim status confirmed through counsel, an advocate, a prosecutor, court material, or another appropriate source: [________________________________]

4. COVERED LEGAL-PROCEEDING PURPOSE

The requested leave relates to the incident or offense and is for:

• ☐ Seeking legal assistance or remedies to ensure health and safety
• ☐ 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
• ☐ Attending a related civil court proceeding
• ☐ Attending a related criminal court proceeding

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

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

Proceeding or preparation date and time: [________________________________]

Expected work absence: [DATE / START / END]

5. LEAVE AMOUNT AND PAY COORDINATION

The NJ SAFE Act provides up to 20 days of unpaid leave in one 12-month period following an incident. Each incident may support a leave route, but the employee may not exceed the allotted 20 days in the applicable 12-month period. Leave may be taken intermittently in increments of no less than one day.

The employee may elect to use accrued paid vacation, personal, medical, or sick leave or available family temporary disability benefits. Elected paid leave or benefits run concurrently with the otherwise unpaid NJ SAFE Act leave.

• ☐ Unpaid leave requested
• ☐ Accrued paid leave elected: [TYPE / DAYS]
• ☐ Family temporary disability benefits elected or under review
• ☐ Concurrent Family Leave Act or federal FMLA review required

6. NOTICE

When leave is foreseeable, the employee must provide written notice as far in advance as is reasonable and practical. An emergency or other unforeseen circumstance may preclude prior notice.

• ☐ Foreseeable leave; written notice delivered as far in advance as reasonable and practical
• ☐ Emergency or other unforeseen circumstance precluded prior notice

Notice date, method, and recipient: [________________________________]

Employee or designee: _________________________ Date: ______________

7. DOCUMENTATION, IF REQUIRED

If the employer requires support, provide one or more permitted records using the least revealing option reasonably available:

• ☐ Domestic-violence restraining order or other court documentation of equitable relief
• ☐ County or municipal prosecutor documentation
• ☐ Documentation of a conviction for the domestic violence or sexually violent offense
• ☐ Medical documentation
• ☐ Certification from a certified Domestic Violence Specialist or the director of a designated domestic-violence agency or Rape Crisis Center
• ☐ Other qualifying documentation or certification from a social worker, member of the clergy, shelter worker, or other professional who assisted the victim

Secure delivery date and method: [________________________________]

Do not attach a police narrative, protected address, complete medical record, or other sensitive material when a less revealing permitted record is sufficient.

8. CONFIDENTIALITY AND EMPLOYER RESPONSE

Information regarding the leave and the domestic violence or sexually violent offense must be retained in the strictest confidentiality, subject to the limited statutory disclosure exceptions.

• ☐ Employer and employee eligibility confirmed
• ☐ Victim and relationship gate confirmed
• ☐ Covered legal-proceeding purpose confirmed
• ☐ 12-month period and remaining days confirmed
• ☐ Notice or emergency route confirmed
• ☐ Documentation received or calendared
• ☐ Leave approved in increments of at least one day
• ☐ Paid-leave or benefit election recorded: [________________________________]
• ☐ Strict confidential-storage and access controls applied
• ☐ Counsel review required

Employer representative: _____________________ Date: ______________

9. NONRETALIATION AND DEADLINE ALERT

An employer may not discharge, harass, discriminate, retaliate, or threaten those actions regarding compensation, terms, conditions, or privileges of employment because an employee took or requested NJ SAFE Act leave or refused to authorize release of confidential information.

N.J.S.A. 34:11C-5 permits an employee or former employee to bring a Superior Court civil action and lists common-law tort remedies, civil fines, injunctive relief, reinstatement, restored benefits and seniority, lost compensation, costs, and attorney fees. The action must be commenced within one year of the alleged violation, and the statutory private cause of action is the sole remedy for an NJ SAFE Act violation. Obtain prompt legal advice; this packet is not a complaint.

10. CHANGE LOG

OFFICIAL SOURCES VERIFIED

• New Jersey Legislature — current Statutes database
• P.L.2013, c.82 — NJ SAFE Act, N.J.S.A. 34:11C-1 to -5
• P.L.2019, c.37 — current family scope, employee election, and notice amendment