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Employee DV Supplement

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EMPLOYEE DOMESTIC VIOLENCE (DV) SUPPLEMENT

Purpose: This form supplements the employee personnel record and documents requests for leave, workplace safety planning, and reasonable accommodations arising from incidents of domestic violence, stalking, sexual assault, or related threats. Information provided will be treated as confidential to the extent permitted by law and company policy.

Personal Information

Phone:

Email:

Position Information

Reporting Manager:

Start Date:

Incident Summary

Date of most recent incident:    Location:

Has this matter been reported to law enforcement? Yes No

Police report number:

Law enforcement contact:

Is there an active protective or restraining order related to this matter? Yes No

Protective order date:

Case number / court:

Safety Concerns and Immediate Needs

Do you request workplace safety measures (select all that apply):

Change parking location or permit
Screen calls and block numbers from workplace records
Temporary change to work schedule or location
Security escort to/from vehicle or transit
Other (describe below)

Leave Request

Type of leave requested: Paid leave Unpaid leave Short-term disability Leave under applicable statutory protections

Leave start date:

Estimated return date:

Emergency Contacts / Support Persons

Phone:

Relationship:

Authorization & Information Sharing

I authorize the Human Resources department and designated representatives to obtain and verify information reasonably necessary to evaluate my request for leave or accommodation, including verification of protective orders, law enforcement reports, and other relevant records. I understand the employer will limit disclosure of information to those with a business need to know and will maintain confidentiality consistent with applicable law.

I authorize the employer to contact my emergency contact or support person for the purpose of providing safety information or in an emergency: Yes No

I also authorize the employer to contact prior employers and third parties as necessary to verify employment history and any information I have provided for the purposes of processing this request and any associated leave or accommodation: I consent

Employment History

Title:

Dates Employed:

Title:

Dates Employed:

Education

Graduation date:

References

Phone:

Relationship:

Phone:

Relationship:

Phone:

Relationship:

Legal Disclosures

At-Will Employment: Nothing in this form alters the at-will nature of employment unless a separate written agreement signed by authorized company officials explicitly states otherwise.

Equal Employment Opportunity: The employer does not tolerate discrimination or retaliation. Requests for leave or accommodation made under this supplement will not be used as a basis for adverse employment action, and retaliation against an individual for requesting protections is prohibited and subject to discipline.

Employee Certification and Authorization

I certify that the information I have provided in this Employee DV Supplement is true and complete to the best of my knowledge. I understand that knowingly providing false information may result in disciplinary action up to and including termination. I authorize the employer to verify any information contained herein as necessary to evaluate requests for leave or reasonable accommodation. I understand the employer will maintain confidentiality except as required to implement safety measures, comply with legal obligations, or protect workplace safety.

I understand that accommodations or leave approvals may be subject to verification of need and that approval is based on available resources and applicable law and policy.

Employee Printed Name:

Employee Signature:

Date Signed:

HR Use Only

HR Printed Name:

By:

Date:

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What the Employee DV Supplement Is and when it’s used

The Employee DV Supplement is a supplemental HR form used to document and support an employee’s request for protections, leave, or workplace accommodations related to domestic violence, stalking, or intimate partner violence. It records confidential details such as incident dates, safety concerns, contact preferences, and documentation (orders of protection, police reports, medical records) that help employers assess reasonable accommodations, time-off requests, and safety planning. Employers commonly attach this supplement to personnel files, leave requests, or accommodation workflows to ensure consistent handling while protecting privacy and access to resources.

Why an Employee DV Supplement matters for employers and employees

The supplement creates a consistent, documented path for handling sensitive requests—reducing uncertainty, protecting confidential information, and supporting compliance with leave and accommodation laws such as state domestic-violence leave and federal nondiscrimination obligations.

Why an Employee DV Supplement matters for employers and employees

Who fills and reviews the Employee DV Supplement

Human resources, the employee seeking assistance, and designated managers or security staff typically complete and review the supplement as part of an accommodations or leave request.

  • Employee: Provides incident details, contact preferences, and supporting documents; requests leave or safety measures.
  • HR Specialist: Reviews documentation, evaluates eligibility for leave or accommodation, and coordinates confidentiality safeguards.
  • Security/Facilities: Implements physical or access changes, notifies building security, and updates badge access as needed.

Maintain limited distribution and follow privacy rules; retain only the information needed for the accommodation or leave decision.

How to complete the Employee DV Supplement step by step

Follow these four steps to submit a clear, secure request that HR can act on quickly.

  • 01
    Prepare Documents: Gather police reports, protection orders, and medical or counselor notes to support your request.
  • 02
    Complete Form: Enter personal and incident details, indicate requested accommodations, and attach supporting documents.
  • 03
    Submit Securely: Deliver the supplement to designated HR contact via secure channel or approved eSubmission method.
  • 04
    HR Response: HR reviews, may request clarification, and issues an accommodation decision or leave authorization.

Essential components included in a professional Employee DV Supplement

A complete supplement balances necessary detail with strict confidentiality controls to support decision-making without oversharing sensitive information.

Identifying Information

Employee name, job title, department, and preferred contact methods to link the supplement to personnel records securely.

Incident Summary

Brief factual description of incidents, locations, and dates; avoids speculative or inflammatory language.

Requested Accommodations

Specific actions requested such as leave duration, schedule changes, remote work, parking reassignment, or physical security measures.

Documentation Checklist

Space to list or attach protective orders, police reports, medical notes, or advocacy letters used to substantiate the request.

Confidentiality Notice

Statement describing who will see the form and how information will be stored and limited to those with a need to know.

Decision Log

HR section for recording actions taken, dates, and any follow-up required to create an audit trail for compliance.

Typical routing and handling workflow for the supplement

A clear routing path reduces delay and maintains privacy—this sequence shows who receives the form and when.

  • Employee Submission: Employee completes and submits the supplement through HR portal or secure email.
  • HR Intake: HR logs receipt, limits access, and confirms any immediate safety steps.
  • Assessment: HR evaluates documentation, legal obligations, and feasibility of requested accommodations.
  • Implementation: Approved accommodations are implemented and documented; follow-up scheduled as needed.

How to configure an online review workflow

Set clear roles, notifications, and access controls in your HR system before accepting submissions.

Field Configuration
Intake Recipient Designated HR inbox with limited access
Reviewer Role HR manager + legal liaison for complex cases
Notification Email or secure portal alert to HR and manager with no details in subject line
Retention Flag Mark record as sensitive; restrict export and print permissions

Technical and security considerations for eSubmission

Use a platform that supports encryption, role-based access, and an auditable history when accepting sensitive employee submissions.

  • File Formats: PDF or DOCX for attachments; prefer PDF/A for long-term retention
  • Access Controls: Role-based permissions and audit logging for all viewers
  • Authentication: Multi-factor or secure single-sign-on for HR reviewers

Ensure your chosen system supports secure storage and controlled sharing; maintain minimal distribution and maintain an audit trail for compliance.

Sensitive-data handling elements to include on the form

Encryption: TLS 1.2/1.3 and AES-256 at rest
Access Logging: Detailed audit trail of views and downloads
Limited Distribution: Restricted to HR, legal, and safety staff on an as-needed basis
Data Minimization: Collect only what’s required for decision-making
HIPAA Consideration: Medical records may implicate HIPAA; handle via BAA where required
Record Disposal: Secure deletion or archived retention per policy

Consequences of mishandling or incomplete supplements

Privacy Breach: Unauthorized disclosure can create legal liability and workplace safety risks
Retaliation Claims: Failure to accommodate may lead to discrimination or retaliation litigation
Regulatory Penalties: State leave violations can carry fines or administrative remedies
Operational Risk: Incomplete information delays safety planning and increases risk
Recordkeeping Errors: Poor retention practices impede audits and defense in disputes
Incorrect Disclosure: Overbroad sharing may violate HIPAA, state privacy laws, or company policy

Common mistakes to avoid when preparing this supplement

  • Including unnecessary personal details that increase risk without aiding decisions
  • Using unsecured email or attachments for submission instead of protected portals
  • Failing to record who accessed the file and why, hindering auditability
  • Not tracking follow-up steps or decision dates, which causes compliance gaps

Timing considerations and expected processing windows

Processing times vary by employer size, documentation needed, and applicable state leave rules; plan for prompt intake and timely responses.

Initial Acknowledgment:

Within 2 business days after HR receives the supplement

Interim Safety Steps:

Immediate if imminent risk; implemented upon intake

Documentation Request:

Within 5–10 business days when verification is needed

Decision on Accommodation:

Typically within 10–15 business days after complete documentation

Appeal or Reconsideration:

Employer policy should define a 7–14 day window

Key milestones from submission to implementation

This sequence maps the main stages and expected employer actions after the supplement is submitted.

01

Submission Received

HR logs form, applies confidentiality flags, and sends acknowledgment.

02

Immediate Safety Review

Assess immediate threats and take emergency steps if necessary.

03

Documentation Verification

Request and review supporting documents to determine eligibility.

04

Accommodation Decision

Approve, modify, or deny with documented rationale and next steps.

eSignature vendor comparison for secure, confidential submissions

Key plan and compliance differences matter when choosing a platform to accept confidential Employee DV Supplement submissions.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies by plan Varies by plan Varies by plan Varies by plan
Bulk Send Yes Varies by plan Varies by plan Varies by plan Varies by plan
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No cap 100 envelopes/user/year Varies by plan Varies by plan Varies by plan

Frequently asked questions about the Employee DV Supplement

Answers to common questions about confidentiality, documentation, and eSubmission for Employee DV Supplements.


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