Election-Worker Service Leave Request and Appointing-Authority Certification Packet - Nebraska
ELECTION-WORKER SERVICE LEAVE REQUEST AND APPOINTMENT CERTIFICATION
Nebraska — Neb. Rev. Stat. § 32-241
This packet is for service as an appointed election worker. It is not a request for time off to vote.
1. EMPLOYEE AND EMPLOYER
| Field | Entry |
|---|---|
| Employee | [________________________________] |
| Employer | [________________________________] |
| Position / worksite | [________________________________] |
| Normal shift | [DATE / START / END] |
| HR / supervisor | [________________________________] |
2. APPOINTED ROLE
County: [________________________________]
Election: [TYPE / DATE]
Appointing official: [ELECTION COMMISSIONER / COUNTY CLERK / OTHER]
Role:
- ☐ Judge of election
- ☐ Clerk of election
- ☐ Precinct or district inspector
- ☐ Canvassing board member
- ☐ Other election worker: [________________________________]
Appointment date: [________________________________]
- ☐ Regular appointment
- ☐ Judge or clerk appointed on election day to fill a vacancy
3. REASONABLE NOTICE
The employee gives notice of the appointment on [DATE / TIME] by [METHOD].
Recipient: [________________________________]
Section 32-241 requires reasonable notice, except that reasonable notice is waived for a judge or clerk appointed on election day to fill a vacancy.
Employee signature: __________________________ Date: ______________
4. SERVICE AND SHIFT-RELIEF REQUEST
Required service begins: [DATE / TIME]
Required service ends: [DATE / TIME]
Total required service hours: [________]
The employee requests excusal from shift work, without loss of pay, for:
- ☐ The hours the employee is required to serve.
- ☐ Eight hours before required service because service will be eight hours or more.
- ☐ Eight hours after required service because service will be eight hours or more.
Requested excusal period: [START / END]
5. APPOINTING-AUTHORITY CERTIFICATION
I certify that [EMPLOYEE] was appointed in [COUNTY] for the role and election identified above.
| Certification item | Entry |
|---|---|
| Required service hours | [________________________________] |
| County hourly compensation, excluding expenses | $[________] |
| Expense reimbursement, if any | $[________] |
| Election-day vacancy appointment | ☐ Yes ☐ No |
| Verification contact | [________________________________] |
Appointing official signature: __________________ Date: ______________
Printed name / title: [________________________________]
6. EMPLOYER PAYROLL AND SCHEDULING REVIEW
Section 32-241 protects against discharge, lost pay, lost overtime pay, lost sick leave, lost vacation time, threats, and other penalties because of covered service. An employer may reduce pay for each missed work hour by the county's hourly election-worker compensation other than expenses.
| Payroll item | Entry |
|---|---|
| Scheduled work hours excused | [________] |
| Protected pre-service rest hours | [________] |
| Protected post-service rest hours | [________] |
| County hourly service compensation | $[________] |
| Permitted hourly wage offset | $[________] |
| Expense reimbursement excluded from offset | $[________] |
| Sick / vacation reduction | 0 |
- ☐ Schedule and payroll treatment approved
- ☐ Election-day vacancy notice waiver recorded
- ☐ Service was under eight hours; extended rest rule not applied
- ☐ Counsel review required
Employer representative: _____________________ Date: ______________
Decision delivered to employee: [DATE / METHOD]
7. POST-SERVICE CONFIRMATION
Actual service start and end: [________________________________]
Actual county compensation other than expenses: $[________]
Actual expense reimbursement: $[________]
Appointing official / payroll confirmation: [________________________________]
Any correction to employer payroll: [________________________________]
8. COMPLIANCE NOTE
A violation of § 32-241 is a Class V misdemeanor. Route any threatened discharge, leave-bank deduction, unpermitted wage loss, or other penalty for prompt counsel review.
Issue and response: [________________________________]
OFFICIAL SOURCE VERIFIED
About this template
- Last updated
- August 10, 2026
- Citations checked
- August 10, 2026
- Jurisdiction
- Nebraska
- Category
- Employment & HR
Legal authority
- Neb. Rev. Stat. § 32-241 (election-worker employment protection, notice, shift relief and rest periods, wage offset, and penalty)
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.
Not legal advice
This template is provided for informational purposes. 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 August 10, 2026.
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