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

DELAWARE VOLUNTEER EMERGENCY-RESPONDER ABSENCE AND VERIFICATION PACKET

19 Del. C. §§ 1801-1808

1. COVERAGE WORKSHEET

• ☐ Employer has at least 10 employees.
• ☐ Employee is a volunteer firefighter, volunteer fire-company ladies-auxiliary member, volunteer EMT, or volunteer fire police officer.

Protected route:

• ☐ Governor-declared state-of-emergency response, not exceeding seven consecutive days
• ☐ President-declared national-emergency response, not exceeding fourteen consecutive days
• ☐ Absence caused by an injury sustained while acting as a volunteer emergency responder

Declared-emergency exclusions:

• ☐ Employee is not an essential state employee, armed-forces or National Guard member, covered hospital employee, or necessary public-utility/VoIP/cellular-network employee.
• ☐ Exclusion or substantially similar employer-policy review is required: [________________________________]

2. EMPLOYEE NOTICE

To: [EMPLOYER / SUPERVISOR]

I may be absent from work because of the covered event identified above. I am giving notice under the employer's existing policy, if any.

I understand the employer may subtract the missed time from earned wages.

Employee signature: __________________________ Date: ______________

3. RESPONDER-AUTHORITY STATEMENT

At the employer's request, return this statement within seven days.

I verify that [EMPLOYEE] responded to an emergency.

Authorized department representative: __________________ Date: __________

4. MEDICAL STATEMENT FOR INJURY ABSENCE

At the employer's request, return this statement within five days.

I verify that [EMPLOYEE] was seen on [DATE]. Estimated partial or total incapacity to perform the employee's job: [________________________________].

Medical professional / authorized representative: __________________________

Date: ______________ Contact: [________________________________]

5. EMPLOYER RECORD

• ☐ Employee notice received under policy
• ☐ Seven-day responder statement requested / received
• ☐ Five-day medical statement requested / received
• ☐ Wage adjustment recorded
• ☐ Exclusion analysis completed
• ☐ No termination, demotion, or discipline based on covered absence

A covered violation may require reinstatement without reduction of wages, seniority, or benefits, lost wages or benefits, court costs, and reasonable attorney fees. The employee's Superior Court action must be commenced within one year after the violation.

Employer representative: ______________________ Date: ______________

OFFICIAL SOURCE VERIFIED

• Delaware Code Online — Title 19, Chapter 18