Crime-Victim and Witness Court-Attendance Leave Request Packet
CRIME-VICTIM, FAMILY, OR WITNESS COURT-ATTENDANCE REQUEST PACKET
Pennsylvania — 18 Pa.C.S. § 4957
Section 4957 protects an employee who attends court because the employee is a victim of, witness to, or qualifying family member of a victim of a crime. It is not a general jury-duty, civil-witness, investigation-interview, or noncourt cooperation form.
1. EMPLOYEE AND EMPLOYER
| Field | Entry |
|---|---|
| Employee | [________________________________] |
| Employer | [________________________________] |
| Position / department | [________________________________] |
| HR / supervisor contact | [________________________________] |
| Preferred confidential contact | [________________________________] |
2. COVERED-ROLE GATE
Select one route:
- ☐ Direct victim. A crime was committed or attempted against the employee, the employee suffered the harm described in Crime Victims Act § 103, and the employee is not the alleged offender.
- ☐ Witness. The employee attends court because the employee is a witness to a crime.
- ☐ Victim's family member. The employee attends court because the employee is a member of a direct victim's family.
For the family route, Crime Victims Act § 103 includes a person related to the victim within the third degree of consanguinity or affinity, a person maintaining a common-law relationship with the victim, or a person residing in the same household.
Relationship, if the family route is selected: [________________________________]
Coverage confirmed by prosecutor, victim advocate, or counsel: [NAME / OFFICE / DATE]
3. COURT-ATTENDANCE GATE
Court: [________________________________]
Case identifier, using the minimum information needed: [________________________________]
Reason for attendance:
- ☐ Crime victim
- ☐ Crime witness
- ☐ Qualifying family member of crime victim
Proceeding date and time: [________________________________]
Expected work absence: [DATE / START / END]
Travel or waiting time requested: [________________________________]
Do not attach charging papers, police reports, medical records, a victim address, or a detailed offense narrative unless current law or counsel specifically requires it.
4. EMPLOYEE NOTICE AND REQUEST
Section 4957 does not state a fixed advance-notice deadline. The employee provides this operational notice on [DATE / TIME] and requests the following work absence:
[____________________________________________________________]
Minimum supporting record, if voluntarily supplied or lawfully requested:
- ☐ Court scheduling notice
- ☐ Subpoena or witness notice
- ☐ Prosecutor or victim-advocate confirmation
- ☐ Other: [________________________________]
Secure delivery method and recipient: [________________________________]
Employee signature: __________________________ Date: ______________
5. PAY AND BENEFITS TREATMENT
Section 4957 does not require the employer to compensate employment time lost because of covered court attendance.
- ☐ Unpaid time
- ☐ Apply accrued paid leave if available: [TYPE / HOURS]
- ☐ Schedule adjustment: [________________________________]
- ☐ Other treatment under policy, agreement, or separate law: [________________________________]
The selected pay treatment does not authorize loss of employment, seniority position, or benefits prohibited by § 4957.
6. EMPLOYER RESPONSE
- ☐ Covered employee role confirmed
- ☐ Crime-related court attendance confirmed
- ☐ Absence recorded for [DATE / START / END]
- ☐ Pay treatment recorded
- ☐ Counsel or labor-relations review required
Section 4957 prohibits an employer from depriving the employee of employment, seniority position, or benefits, or threatening or coercing the employee regarding them, because of covered court attendance.
Employer representative: _____________________ Date: ______________
Decision delivered to employee: [DATE / METHOD]
Confidential storage location / access role: [________________________________]
7. COMPLIANCE RECORD
Section 4957 provides a summary-offense penalty and a civil route for actual lost wages and benefits, reinstatement, and a reasonable attorney fee for a prevailing employee. Record any dispute for prompt counsel review.
Issue raised: [________________________________]
Interim protection taken: [________________________________]
Counsel / HR follow-up: [________________________________]
8. CHANGE OR CANCELLATION LOG
| Date | Court update | Employee notice to employer | Revised work schedule |
|---|---|---|---|
| [________] | [________________] | [________________] | [________________] |
| [________] | [________________] | [________________] | [________________] |
OFFICIAL SOURCES VERIFIED
About This Template
Employment documents govern the relationship between a company and its workers, from offer letters and employment agreements through handbooks, performance reviews, and separations. Done right, they set clear expectations, protect against wrongful termination and discrimination claims, and give both sides a record to rely on. Done poorly, they invite lawsuits, agency complaints, and costly disputes.
Important Notice
This template is provided for informational purposes. It is not legal advice. We recommend having an attorney review any legal document before signing, especially for high-value or complex matters.
Checked against the law it cites
A reviewer verified this template's legal citations against the official source on 2026-08-10.
Legal authority: 18 Pa.C.S. § 4957 (employment protection for court attendance by a crime victim, witness, or victim's family member; pay and remedies); Crime Victims Act, 1998 Pa. Laws 882, No. 111, § 103 (incorporated direct-victim and family definitions)
Last updated: 2026-08-10
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