NATSIC-AS
Family and domestic violence leave request

How to use this letter
Use a safe device and contact method. Provide only the information needed for the request. Check the leave arrangements applying to your employment, including any notice or evidence requirements. This template does not specify a universal entitlement or number of days.

[Date]
To [authorised manager or HR contact]
From [name and employee reference]

Dear [name]

I request [family and domestic violence leave / another applicable leave arrangement] for [dates or hours] because I need to deal with circumstances involving family and domestic violence.

I request that this communication and any supporting information be handled sensitively and shared only as required for the authorised employment process.

Leave and work arrangements
Dates or hours requested: [details]
If the precise period is not yet known: [expected review date or update arrangement]
Proposed handover or urgent work contact: [only if safe and practical]
Other temporary work arrangement requested: [optional]

Safe communication
Please contact me by [safe method] at [safe time].
Please [leave no voicemail / do not send mail to my usual address / other relevant instruction].
A safe alternative contact arrangement is [optional].

Please confirm the applicable leave arrangement, the person authorised to handle this request and any evidence that is reasonably required under the applicable framework. I would like to discuss a safe way to provide any necessary evidence before sending sensitive material.

Please let me know the outcome and any practical arrangements for payroll and return to work. I will update [authorised contact] if the dates or communication arrangements change.

Yours sincerely
[Name]

Before sending
Remove any unsafe contact information. Do not identify a person's location, children's details, refuge or other sensitive information unless necessary and safe to disclose. Consider a support person or advocate for the employment discussion.

Source and use information
Original NATSIC-AS advocacy preparation template. Leave eligibility and any evidence requirements must be checked against the applicable employment framework.
NATSIC-AS provides advocacy, not legal advice or legal services. Check applicable requirements and deadlines before use.