Family Violence Leave TS

Family Violence Leave TS

This form is to be used by an employee for an application for leave for family violence reasons. This leave type is not available in Employee Self-Service. The information collected on this form is required to process the application. Information regarding eligibility for leave is available on HRWeb at:

Privacy: The information collected on this form is for the purpose set out and is required to process your request. Your information will not be disclosed without your consent or unless authorised or required by law.You are able to request access to the personal information the Department holds about you and request it be corrected by contacting your Principal.Information about contacting the People Division is available at: Information about the Department’s privacy policy is available at:
Employee Details
Family Name: / Given Name: / Employee ID:
School Name: / Division/Region (if applicable):
Period of Absence
Start date:______/ ______/ ______End date:______/ ______/ ______
Partial Hours(where an absence begins or ends part-way through the day) / Start day(hours absent) ……………………End day(hours absent) …………………….
Evidence
The application for family violence leave must include relevant supporting documentary evidence that indicates the applicant is experiencing family violence.
Evidence may be:
a statutory declaration, or
a document issued by one of the following:
 Victoria Police or another police service
 a Court
 a registered health practitioner
 a Family Violence Support Service /  a district nurse
 a maternal and child health nurse
 a lawyer
Declaration by Employee
I give consent for this application to be kept on my personnel file: / Yes / No
Employee’s Signature: ...... Date: ______/ ______/ ______
Additional Information
  • The employee may make the request for family violence leave through their principal, who is responsible for forwarding the application to the Manager, Schools People Services (details below).
  • The employee may elect to make their request for family violence leave directly to the Manager, Schools People Services.
  • Principals are not authorised to approve family violence leave.
  • Copies of the application and supporting documentation submitted willnot to be kept by the School on the employee’s personnel file without the employee’s consent on this form. If consent is not provided on this form the leave application will be stored securely in a central Department location.
  • Completed forms and associated documentation for final approval are to be addressedto the Manager, Schools People Services and sent to:
  • It may be necessary for the Manager, Schools People Services to contact the employee’s principal regarding the family violence leave application.

Declaration by People Services Delegate
Application for leave has been: / Approved / Not Approved
People Division Delegate’s Signature: ______
People Division Delegate’s Name (please print): ______Date: ______/ ______/ ______
Office Use Only – where leave is approved
EduPay updated by: Date: ______/ ______/ ______
Office Use Only – where leave is not approved
Employee notified by: Date: ______/ ______/ ______

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