Volunteer Emergency-Responder Work-Absence Notice and Verification Packet - Vermont
VERMONT CERTIFIED EMERGENCY-VOLUNTEER LEAVE PACKET
State employees — 3 V.S.A. § 265
1. ELIGIBILITY WORKSHEET
| Field | Entry |
|---|---|
| Employee | [________________________________] |
| State agency | [________________________________] |
| Supervisor | [________________________________] |
| Red Cross unit | [________________________________] |
- ☐ Employee is a Vermont State employee.
- ☐ Employee is a certified American Red Cross disaster-relief service volunteer.
- ☐ American Red Cross requested the employee's specialized disaster-relief services.
Qualifying service route:
- ☐ Services will be performed in Vermont
- ☐ Federal or presidentially declared disaster designated Red Cross Level III or above
- ☐ Disaster declared by the governor of a state or territory
Prior leave in the current fiscal year: [____] working days.
Requested leave: [____] working days.
- ☐ Aggregate will not exceed 15 working days.
2. EMPLOYEE REQUEST
I request leave from [START] through [END] to perform specialized American Red Cross disaster-relief service work.
Disaster, declaration, level, and location: [________________________________]
Expected duties: [________________________________]
Employee signature: __________________________ Date: ______________
3. RED CROSS REQUEST AND CERTIFICATION
The American Red Cross requests the services of [EMPLOYEE], a certified disaster-relief service volunteer.
| Item | Verification |
|---|---|
| Disaster / declaration | [________________________________] |
| Red Cross level, if applicable | [________________________________] |
| Service location | [________________________________] |
| Service period and duties | [________________________________] |
Red Cross official: __________________________ Date: ______________
4. SUPERVISOR AUTHORIZATION AND PAY REVIEW
- ☐ Leave authorized for [____] working days
- ☐ More information required: [________________________________]
- ☐ Leave not granted: [________________________________]
Pay route:
- ☐ Services in Vermont — regular pay applies
- ☐ Services outside Vermont — Governor authorized pay
- ☐ Services outside Vermont — no gubernatorial pay authorization documented; counsel / payroll review required
If paid under § 265, the employee receives regular pay based on regular work hours. Granted leave does not reduce seniority, accumulated vacation leave, sick leave, or earned overtime.
The State is not liable for workers' compensation claims arising from the disaster-relief service work.
Supervisor: __________________________________ Date: ______________
5. COMPLETION LOG
Actual service period and duties: [________________________________]
Payroll and benefit reconciliation: [________________________________]
OFFICIAL SOURCE VERIFIED
About this template
- Last updated
- August 10, 2026
- Citations checked
- August 10, 2026
- Jurisdiction
- Vermont
- Category
- Employment & HR
Legal authority
- 3 V.S.A. § 265 (Certified emergency-volunteer leave for State employees)
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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