Volunteer Emergency-Responder Work-Absence Notice and Verification Packet - New Hampshire
VOLUNTEER EMERGENCY-RESPONDER WORK-ABSENCE NOTICE AND VERIFICATION PACKET
New Hampshire — RSA 275:41-e
Use this packet only when a covered volunteer firefighter or emergency medical technician witnesses or comes upon an emergency while traveling to work and therefore cannot report at the start of regular working hours.
1. COVERAGE WORKSHEET
| Field | Entry |
|---|---|
| Employee | [________________________________] |
| Employer / worksite | [________________________________] |
| Supervisor / HR | [________________________________] |
| Scheduled report time | [__/__/____ at ________] |
| Fire or ambulance department | [________________________________] |
| Chief | [________________________________] |
Responder status:
- ☐ Volunteer firefighter
- ☐ Call firefighter
- ☐ Reserve firefighter
- ☐ Permanent-intermittent firefighter
- ☐ Emergency medical technician
Compensated responder service during the preceding six months: [________] hours.
- ☐ The total did not exceed 975 hours.
- ☐ The total may have exceeded 975 hours; do not assert statutory coverage without counsel review.
Trigger facts:
- ☐ The employee witnessed or came upon the emergency while en route to work.
- ☐ The employee responded in the covered responder capacity.
- ☐ The response caused failure to report at the commencement of regular working hours.
- ☐ This is not a request to leave an ongoing shift or attend training.
2. EMPLOYEE NOTICE
To: [EMPLOYER / IMMEDIATE SUPERVISOR]
Notice date and time: [__/__/____ at ________]
While traveling to work on [DATE], I witnessed or came upon [GENERAL EMERGENCY CATEGORY] and responded in my capacity as a [ROLE] with [DEPARTMENT]. My scheduled report time was [TIME]. I [REPORTED / EXPECT TO REPORT] at [TIME].
I am providing the reason for my failure to report at the start of regular working hours. I understand that RSA 275:41-e does not require compensation for the missed period.
Requested payroll treatment, subject to law and policy:
- ☐ Unpaid time
- ☐ Voluntary use of available paid leave: [TYPE]
- ☐ Schedule adjustment: [DETAILS]
Chief-signed timing statement:
- ☐ Attached
- ☐ Requested and will follow
- ☐ Employer has not requested it
Employee signature: __________________________ Date: ______________
3. CHIEF CERTIFICATION
I, [CHIEF NAME], certify from department records that [EMPLOYEE] responded to and returned from the emergency at these times:
| Fact | Date and time |
|---|---|
| Response began | [__/__/____ at ________] |
| Employee returned from emergency | [__/__/____ at ________] |
General incident category: [________________________________]
This statement omits patient, victim, and private-location details not needed for employment verification.
Chief signature: __________________________ Date: ______________
Department contact: [________________________________]
4. EMPLOYER RECORD
| Review item | Entry |
|---|---|
| Employee notice received | [________________________________] |
| Chief statement requested / received | [________________________________] |
| Missed work period | [________________________________] |
| Payroll code | [________________________________] |
| Attendance notation | [________________________________] |
RSA 275:41-e bars discharge or discipline for a covered failure to report. A violation may support reinstatement, lost pay or benefits, and a Superior Court action commenced within one year. Counsel should review any disputed coverage or adverse action.
Employer representative: ____________________ Date: ______________
5. DELIVERY LOG
| Date / time | Item | Method | Receipt / follow-up |
|---|---|---|---|
| [________] | [________________] | [________] | [________________] |
| [________] | [________________] | [________] | [________________] |
OFFICIAL SOURCE VERIFIED
About this template
- Last updated
- August 10, 2026
- Citations checked
- August 10, 2026
- Jurisdiction
- New Hampshire
- Category
- Employment & HR
Legal authority
- N.H. Rev. Stat. § 275:41-e (employment protection when a qualifying volunteer firefighter or EMT encounters an emergency while traveling to work; notice, proof, pay, remedies, and one-year action period)
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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