Volunteer Emergency-Responder Work-Absence Notice and Verification Packet - Arkansas

ARKANSAS PUBLIC-EMPLOYEE DISASTER AND EMERGENCY-RESPONSE LEAVE PACKET

Ark. Code Ann. §§ 12-85-102 and 21-4-104; State Personnel Policy 50

This packet documents two separate Arkansas paid-leave routes. Select one route and complete only its applicable sections.

1. PUBLIC-EMPLOYER COVERAGE GATE

Employer type:

• ☐ State agency
• ☐ State-supported institution of higher education
• ☐ City of the first class
• ☐ City of the second class
• ☐ Incorporated town
• ☐ County

• ☐ School district

• ☐ Employer HR confirms that the selected route covers this employee and employer.

This packet does not create a leave entitlement for a private-employer employee. The Red Cross route in Section 3 is limited to a State agency or State-supported institution of higher education. The emergency-and-rescue route in Section 4 applies only to the public-employer categories stated in Ark. Code Ann. § 21-4-104(a).

2. SELECT ONE ROUTE

• ☐ Route A — American Red Cross Disaster Service: discretionary paid leave under § 12-85-102 and State Personnel Policy 50.
• ☐ Route B — Emergency and Rescue Services: paid leave under § 21-4-104 for qualifying Civil Air Patrol, Coast Guard Auxiliary, or federal disaster-team service.

Selected route and reason: [________________________________]

3. ROUTE A — AMERICAN RED CROSS DISASTER SERVICE

Complete this section only for Route A.

3.1 Eligibility, request, and location

• ☐ Employee works for a State agency.
• ☐ Employee works for a State-supported institution of higher education.
• ☐ Employee is trained and certified as an American Red Cross disaster-service volunteer.
• ☐ The American Red Cross requested the employee's specialized disaster-relief services in connection with a disaster.
• ☐ Services will occur in Arkansas.
• ☐ Services will occur in a state contiguous to Arkansas: [________________________________]
• ☐ The State-agency director or head of the State-supported institution consents to the leave.

Written Red Cross request attached: ☐ Yes ☐ No

3.2 Calendar-year balance and statewide ceiling

• ☐ Total does not exceed 15 working days in the calendar year.
• ☐ Agency HR completed any required coordination concerning Policy 50's ceiling of 100 certified disaster-service-volunteer State and institution employees on leave at one time.

3.3 Route A pay and balances

If granted, Route A leave is paid at the employee's regular rate for regular work hours missed, without loss of seniority, pay, annual leave, sick leave, compensatory time, offset time, or overtime wages.

• ☐ Regular work hours missed: [________]
• ☐ State Personnel Policy 50 leave code recorded as Disaster Service.
• ☐ Additional earned leave requested separately, if needed: [________________________________]

4. ROUTE B — EMERGENCY AND RESCUE SERVICES

Complete this section only for Route B.

4.1 Select the qualifying organization and trigger

• ☐ United States Civil Air Patrol: member participating in a Civil Air Patrol training program or emergency and rescue services at the request of the wing commander or designated representative.
• ☐ United States Coast Guard Auxiliary: member participating in a Coast Guard Auxiliary training program or emergency and rescue services at the request of the applicable authorized official.
• ☐ National Disaster Medical System, Disaster Mortuary Operational Response Team, or Disaster Medical Assistance Team: member responding under a United States Department of Health and Human Services National Disaster Team Alert Order for qualifying training or emergency and rescue services.

4.2 Required organizational authorization

Authorization or order type:

• ☐ Civil Air Patrol wing commander request
• ☐ Wing commander's designated-representative request
• ☐ District 15 Captain request
• ☐ United States Department of Health and Human Services National Disaster Team Alert Order

Written request or alert order attached: ☐ Yes ☐ No

4.3 Calendar-year balance

• ☐ Total does not exceed 15 days in the calendar year.
• ☐ Partial-day treatment was confirmed with employer HR: [________________________________]

4.4 Pay and requested insurance contribution

• ☐ Paid Route B leave recorded for [________] days or [________] hours.
• ☐ Employee requests continuation of the employer's portion of life-insurance premiums during leave.
• ☐ Employee requests continuation of the employer's portion of disability-insurance premiums during leave.
• ☐ Employer HR confirms whether § 21-4-104(e) covers this employer and the steps required to maintain continuous coverage.

Section 21-4-104(e) expressly lists the State, a city, a county, and a school district. An incorporated-town employer should obtain Arkansas legal review before relying on that subsection's insurance-contribution rule.

5. EMPLOYEE REQUEST OR NOTICE

I request or notify my public employer of paid leave under the selected Arkansas route. I certify that the information in this packet is accurate, authorize verification with the identified organization and officials, and will promptly report any change in my status, authorization, assignment, disaster, service, or dates.

Request or notice delivered on: [__/__/____]

Delivery method / recipient: [________________________________]

Employee signature: __________________________ Date: ______________

6. PUBLIC-EMPLOYER REVIEW AND DECISION

• ☐ Public-employer and employee coverage confirmed.
• ☐ Selected route and all route-specific eligibility gates confirmed.
• ☐ Membership or Red Cross certification confirmed.
• ☐ Organizational request or federal alert order confirmed.
• ☐ Calendar-year balance confirmed.
• ☐ Route A director or institution-head consent granted.
• ☐ Route A statewide-participant coordination completed, if applicable.
• ☐ Paid leave approved or recorded for [________] days or [________] hours.
• ☐ Request denied or limited: [________________________________]
• ☐ Additional documentation requested under lawful employer procedure: [________________________________]
• ☐ Arkansas counsel or public-employer HR review required.

Timekeeping / payroll entry: [________________________________]

Authorized representative: ___________________ Date: ______________

Decision delivered: [DATE / METHOD]

7. POST-SERVICE VERIFICATION

Arkansas's cited provisions do not prescribe one universal verification form. Use this section to document the actual service and reconcile payroll under lawful public-employer procedure.

I verify that [EMPLOYEE] performed or attended the activity described in this packet.

Authorized organization representative: _______ Date: ______________

Printed name / title: [________________________________]

Payroll or leave correction, if any: [________________________________]

OFFICIAL SOURCES VERIFIED

• Arkansas State Personnel Policy 50 — Emergency Leave, Disaster Service Volunteer Leave and Emergency and Rescue Leave (revised May 29, 2024)
• Arkansas General Assembly — Act 20 of 2023