Letterhead of the DV/SA Organization
[Date]
To Whom It May Concern:
I am a domestic violence [and/or] sexual assault advocate from [Name of Organization] for [employee name]. [Employee] was absent from work because [she/he] is undergoing treatment for physical [and/or] mental injuries [and/or] abuse resulting in victimization from an act of domestic violence [and/or] sexual assault.
As a victim of domestic violence [and/or] sexual assault, [employee] needed time off from work [list dates] to obtain or attempt to obtain court relief to help ensure the health, safety, or welfare of [herself/himself] and /or [her/his child].
[If employer has 25 or more employees, you may also/alternatively list the following reasons for taking time off from work:
- To seek medical attention for injuries caused by domestic violence or sexual assault;
- To obtain services from a domestic violence shelter, program, or rape crisis center as a result of domestic violence or sexual assault.
- To obtain psychological counseling related to an experience of domestic violence or sexual assault.
- To participate in safety planning and take other actions to increase safety from future domestic violence or sexual assault, including temporary or permanent relocation.]
Signature