Public Sector Employee: File an exemption
The purpose of this communication is to update you on the critical steps UFCW 21 has taken and is continuing to take to protect member’s privacy and let you know the steps you need to take to file an exemption if you are a victim of domestic violence or have special privacy needs. Please complete the following statements. You will need to include any supporting documentation. Note: Action must be taken by March 31, 2020.
My name is
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First Name
Last Name
I am a public employee working at
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Check this box if true
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I wish to keep my identity and work location private for my safety, and the safety of my family and co-workers.
I am basing my claim for an exemption based on the language in section of the temporary restraining order (TRO).
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a) A police report indicating that the employee or employee’s family member was a victim of domestic violence, sexual assault, or stalking;
b) A court order protecting or separating the employee or employee’s family member from the perpetrator of the act of domestic violence, sexual assault, or stalking, or other evidence from the court or the prosecuting attorney that the employee or employee’s family member appeared, or is scheduled to appear, in court in connection with an incident of domestic violence, sexual assault, or stalking;
c) Documentation that the employee or the employees family member is a victim of domestic violence, sexual assault, or stalking, from any of the following persons from whom the employee or employee’s family member sought assistance in addressing the domestic violence, sexual assault, or stalking: An advocate for victims of domestic violence, sexual assault, or stalking; an attorney; a member of the clergy; or a medical or other professional. The provision of documentation under this section does not waive or diminish the confidential or privileged nature of communications between a victim of domestic violence, sexual assault, or stalking with one or more of the individuals named in this subsection (4)( c) pursuant to RCW 5.60.060, 70.123.075, 70.123.076, or 70.125.065; or
d) An employee’s written statement that the employee or the employee’s family member is a victim of domestic violence, sexual assault, or stalking and that the leave taken was for one of the purposes described in RCW 49.76.030 or the safety accommodation requested pursuant to RCW 49.76.115 is to protect the employee from domestic violence, sexual assault, or stalking, or
e) A court issued temporary protection order or anti-harassment order.
I have attached the following documents to support my request for exemption:
Browse Files
Cancel
of
This is the best email address to contact me
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example@example.com
This is the best phone number to contact me
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Area Code
Phone Number
Submit
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