Volunteer Emergency-Responder Work-Absence Notice and Verification Packet - Connecticut
VOLUNTEER EMERGENCY-RESPONDER WORK-ABSENCE NOTICE AND VERIFICATION PACKET
Connecticut — Conn. Gen. Stat. § 7-322c
1. COVERAGE AND STATUS
| Field | Entry |
|---|---|
| Employee / job | [________________________________] |
| Employer / worksite | [________________________________] |
| Supervisor / HR | [________________________________] |
| Responder organization | [________________________________] |
Covered status:
- ☐ Active volunteer firefighter
- ☐ Active member of a volunteer ambulance service or company
Select the applicable employer gate:
- ☐ Employer is a person engaged in business who has employees.
- ☐ Employer is the State of Connecticut or one of its political subdivisions.
2. REQUIRED STANDING STATUS STATEMENT
Deliver no later than 30 days after the employee is certified in the covered responder role.
I, [NAME AND TITLE], notify [EMPLOYER] that [EMPLOYEE] is an active [VOLUNTEER FIREFIGHTER / MEMBER OF A VOLUNTEER AMBULANCE SERVICE OR COMPANY] with [ORGANIZATION].
Signer role:
- ☐ Chief of the volunteer fire department
- ☐ Medical director of the volunteer ambulance service or company
- ☐ Chief administrator of the volunteer ambulance service or company
Authorized signature: __________________________ Date: ______________
Employee signature: ____________________________ Date: ______________
Employer receipt: ______________________________ Date: ______________
3. FIRE OR AMBULANCE CALL NOTICE
I may be [LATE / ABSENT] because I am responding to a fire or ambulance call [BEFORE / DURING] my regular hours of employment.
| Timing fact | Entry |
|---|---|
| Call date / time | [________________________________] |
| Scheduled work period | [________________________________] |
| Response began | [________________________________] |
| Expected release / update | [________________________________] |
Every effort was made to notify the employer on [DATE / TIME] by [METHOD].
Employee signature: __________________________ Date: ______________
4. NO-PRIOR-NOTICE EXPLANATION
Complete only if the employee could not provide prior notice.
I, [AUTHORIZED SIGNER], state that [EMPLOYEE] could not provide prior notice because:
[____________________________________________________________]
Authorized signature: __________________________ Date: ______________
5. EMPLOYER-REQUESTED RESPONSE VERIFICATION
I verify that [EMPLOYEE] responded to a [FIRE / AMBULANCE] call on [DATE].
Response began: [________] Response ended: [________] Duration: [________]
Authorized signer and role: [________________________________]
Signature: __________________________ Date: ______________
6. PAY AND EMPLOYER RESPONSE
Section 7-322c does not itself state whether the protected absence is paid or charged to leave. Apply only a separately verified law, policy, agreement, or collective-bargaining term.
- ☐ Notice and proof accepted
- ☐ Additional statutory proof requested
- ☐ Pay / leave treatment requires separate review: [________________]
- ☐ Coverage or status requires counsel review
Employer representative: __________________ Date: ______________
The employee must promptly report any change in covered responder status, including termination of that status.
An employee discharged or discriminated against in violation of § 7-322c may bring the statutory Superior Court action within one year and may seek the remedies stated in the section. This packet does not calculate the deadline.
OFFICIAL SOURCE VERIFIED
About this template
- Last updated
- August 10, 2026
- Citations checked
- August 10, 2026
- Jurisdiction
- Connecticut
- Category
- Employment & HR
Legal authority
- Conn. Gen. Stat. § 7-322c (employment protection for active volunteer firefighters and volunteer ambulance members; standing status statement, call notice, proof, status-change notice, and remedies)
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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