Crime-Victim and Witness Court-Attendance Leave Request Packet - Pennsylvania

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

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

OFFICIAL SOURCES VERIFIED

• Pennsylvania General Assembly — 18 Pa.C.S. § 4957
• Pennsylvania General Assembly — Crime Victims Act, including § 103 definitions