Request for Leave for Victims of Domestic and Sexual Violence

This form should be used when requesting accommodations due to domestic or sexual violence.

Effective August 28, 2021, the university will provide employees (whether full-time or part-time) who have been the victim of domestic or sexual violence, or who have a family or household member who has been the victim of domestic or sexual violence, with unpaid leave in accordance with the requirements of Mo. Rev. Stat. § 285.630. For purposes of this type of leave, a “family or household member” means a “spouse, parent, son, daughter, other person related by blood or by present or prior marriage, other persons who share a relationship through a son or daughter, and persons jointly residing in the same household.”

An employee who qualifies for leave under Mo. Rev. Stat. § 285.630 is entitled to a total of two (2) workweeks of leave (i.e., 10 days) during any twelve-month period. An employee may not take unpaid leave that exceeds the amount of unpaid leave time authorized by the FMLA.

Step 1: Review and acknowledge the information below.

Step 2: Submit the completed request form.

For questions about this leave, please contact the Deputy Compliance Officer at DeputyComplianceOfficer@MissouriState.edu or by calling 417-836-6755.

The University reserves the right to require an employee to provide documentation confirming the domestic or sexual violence, consistent with Mo. Rev. Stat. § 285.630.5-6.