Election-Worker Service Leave Request and Appointing-Authority Certification Packet - Virginia

ELECTION-OFFICIAL SERVICE LEAVE REQUEST AND CERTIFICATION

Virginia — Va. Code § 24.2-119.1

This packet is for covered election service. It is not a request for time off to vote.

1. EMPLOYEE AND EMPLOYER

2. COVERED ROLE AND SERVICE

Role:

• ☐ Member of a local electoral board
• ☐ Deputy general registrar
• ☐ Officer of election

Service:

• ☐ At a polling place on election day
• ☐ At a post-election electoral-board meeting to ascertain results under Va. Code § 24.2-671

Election and locality: [________________________________]

Appointment or designation date: [________________________________]

3. REASONABLE NOTICE

The employee gives reasonable notice on [DATE / TIME] by [METHOD].

Notice recipient: [________________________________]

Expected absence: [DATE / START / END]

Employee signature: __________________________ Date: ______________

4. APPOINTING-AUTHORITY CERTIFICATION

I certify that [EMPLOYEE] will serve in the covered role and setting identified above.

Authorized signature: _________________________ Date: ______________

Printed name / title: [________________________________]

5. SHIFT-TIMING PROTECTION

If covered service plus travel is four hours or more, the employee may not be required to start a work shift that:

• begins on or after 5:00 p.m. on the service day; or

• begins before 3:00 a.m. on the following day.

• ☐ Total service plus travel is four hours or more.

• ☐ Shift beginning [DATE / TIME] must be removed or adjusted.
• ☐ Total service plus travel is under four hours; the special shift rule is not invoked.

Revised schedule: [________________________________]

6. EMPLOYER RESPONSE

Section 24.2-119.1 prohibits discharge, adverse personnel action, and required use of sick or vacation time because of the covered absence after reasonable notice. It does not state a general wage-payment rule for the absence.

• ☐ Covered role and service confirmed
• ☐ Reasonable notice recorded
• ☐ Sick and vacation balances will not be charged
• ☐ Shift restriction applied if required
• ☐ Pay treatment under policy or another authority: [________________________________]
• ☐ Counsel / labor-relations review required

Employer representative: _____________________ Date: ______________

7. POST-SERVICE RECORD

Actual service and travel hours: [________________________________]

Schedule and leave-bank reconciliation: [________________________________]

Any threatened or actual adverse action: [________________________________]

A violating employer is subject to the Class 3 misdemeanor stated in § 24.2-119.1.

OFFICIAL SOURCE VERIFIED

• Virginia Law — Va. Code § 24.2-119.1