Volunteer Emergency-Responder Work-Absence Notice and Verification Packet - North Dakota
VOLUNTEER EMERGENCY-SERVICE GOVERNMENTAL LEAVE REQUEST AND RECORD
North Dakota — N.D.C.C. §§ 54-06-14.3, 54-06-27, and 54-06-28
1. EMPLOYMENT AND ROUTE GATE
| Field | Entry |
|---|---|
| Employee | [________________________________] |
| Governmental employer | [________________________________] |
| Position / worksite | [________________________________] |
| Executive officer or governing body | [________________________________] |
| Responder organization | [________________________________] |
Select one route only after counsel or HR review:
- ☐ Section 54-06-14.3(2): full-time state-agency employee; volunteer EMS personnel or volunteer firefighter; response requested by an EMS operation or fire department; paid leave may be granted; all leave under § 54-06-14.3 is capped at five working days per calendar year.
- ☐ Section 54-06-27: full-time state-agency or political-subdivision employee; qualifying declared disaster, specified search emergency, or listed emergency service; leave may be granted up to twenty working days per calendar year.
- ☐ Section 54-06-28: full-time state-agency or political-subdivision employee; volunteer EMS provider, firefighter, emergency radio operator, or Civil Air Patrol member; temporary short-term compensated leave may be granted to answer an emergency call.
This packet is not for a private employer.
2. REQUEST
Requested route: [________________________________]
Emergency, declaration, search, or call: [________________________________]
Requesting organization / authority: [________________________________]
Requested leave period: [START] through [END]
Calendar-year leave already used under the selected section: [________] working days.
I request discretionary approval to provide the volunteer emergency services described above. I will provide status and service verification and will promptly update the employer if the duration changes.
Employee signature: __________________________ Date: ______________
3. ORGANIZATION VERIFICATION
I verify that [EMPLOYEE] is a [ROLE] with [ORGANIZATION] and was requested or called to provide these services:
| Item | Verification |
|---|---|
| Trigger / authority | [________________________________] |
| Service requested | [________________________________] |
| Start / expected end | [________________________________] |
| Actual service period | [________________________________] |
Organization representative: __________________ Date: ______________
Official contact: [________________________________]
4. GOVERNMENTAL EMPLOYER DECISION
- ☐ Approved under § 54-06-14.3 for [____] working days
- ☐ Approved under § 54-06-27 for [____] working days
- ☐ Approved under § 54-06-28 as temporary short-term compensated leave
- ☐ More verification required: [________________________________]
- ☐ Denied after discretionary review: [________________________________]
For leave under §§ 54-06-14.3 and 54-06-27, the approved leave may not cause loss of compensation, seniority, annual leave, sick leave, or accrued overtime otherwise available. Those sections also state that the volunteer is not deemed a governmental employee for workforce-safety-and-insurance purposes during the leave. Section 54-06-28 should be administered according to its own text and agency policy.
Authorized official: __________________________ Date: ______________
5. SERVICE AND PAYROLL RECORD
| Item | Entry |
|---|---|
| Approved workdays / hours | [________________________________] |
| Return date | [________________________________] |
| Compensation preserved | [________________________________] |
| Leave balances preserved | [________________________________] |
| Verification retained | [________________________________] |
Payroll / HR representative: __________________ Date: ______________
OFFICIAL SOURCE VERIFIED
About this template
- Last updated
- August 10, 2026
- Citations checked
- August 10, 2026
- Jurisdiction
- North Dakota
- Category
- Employment & HR
Legal authority
- N.D. Cent. Code § 54-06-14.3 (discretionary state-agency leave for disaster-services, volunteer EMS, and volunteer-firefighter service; five-working-day aggregate and benefit protections)
- N.D. Cent. Code § 54-06-27 (discretionary state-agency or political-subdivision leave for declared disaster, search emergency, and listed volunteer emergency services; twenty-working-day aggregate)
- N.D. Cent. Code § 54-06-28 (discretionary temporary compensated governmental leave for listed emergency-call responders)
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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