Letter to ask for time off or a safety change
A printable from Survivor Job Rights. Fill it in by hand. Nothing you write is collected by this website.
Letter to ask for time off or a safety change
Date: ____________
To: ____________ (supervisor or the person who handles time off)
I am writing to ask for (check what you need):
- Time off from ____________ to ____________ because of a qualifying act of violence against me or my family member
- A change at work to keep me safe, such as: ______________________________
I am asking under California Government Code section 12945.8.
I would like to use my available (check): [ ] paid sick days [ ] vacation [ ] paid time off
Please keep this request and any papers I give you confidential, as the law requires. Please tell me before sharing them with anyone.
If you need proof, I will provide it within a reasonable time.
Please answer in writing by ____________.
Thank you,
Name: ____________ Signature: ____________
Keep a copy of this letter and a photo of any answer. You do not have to describe the violence in detail. Do not write your immigration status.
From Survivor Job Rights. Facts checked October 21, 2026. Free information, not legal or medical advice.