Victims Economic Security and Safety Act (VESSA) Leave of 2026

1. Click ‘Get Form’ to open the Victims Economic Security and Safety Act (VESSA) Leave of Absence Request Form in the editor.
2. Begin by filling in your personal details, including your name, Social Security Number, home address, job title, and department name. Ensure all information is accurate.
3. In the 'Reason for Leave Request' section, select whether the leave is due to domestic or sexual violence affecting you or a family member. Provide the name and relationship of the individual involved.
4. Specify the expected duration of your leave by entering the start and end dates in the designated fields. If you require intermittent leave, describe its anticipated frequency and duration.
5. Indicate which paid time off you wish to apply during your leave by selecting options for vacation, personal holidays, or sick leave. Fill in the hours or days as applicable.
6. Select any benefits you wish to continue during your leave such as medical, vision, dental insurance, etc., ensuring you understand any premium payment requirements.
7. Review all entered information for accuracy before submitting it to your unit HR Administrator at least 48 hours prior to your leave.

Start using our platform today to easily complete your VESSA Leave form online for free!