Parental Leave Request Form

Full Legal Name*

First NameLast Name

CPR Email Address*

example@example.com

What was your hire date?*

Date

Are you FT or PT?*

Full-time benefit eligible (35+ hours)Part-time benefit eligible (30-34 hours)Part-time not benefit eligible (29 hours or less)

What is your expected Parental leave start date?*

Date

Why are you going out on leave?*

Birth of childPlacement of child for adoption / foster care under the age of 17 years oldExpectant spouse

Expected due date of the child:*

Date

Please provide a copy of your adoption or foster legal documents along with your submission for approval.*

Do you anticipate using FMLA in conjunction with your parental leave?*

YesNo

Did you elect into Short Term Disability?*

YesNo

Do you have PTO?*

YesNo

If so, how many hours?*

What is your expected return to work date?*

Date

If the reason you are requesting parental leave is due to the birth of a child, you will need to submit a return to work document from your treating physician no less than one week prior to your return.

Parental Leave Request Form

Your Parental Leave submission is confidential. The health information included will not be viewed by anyone other than HR; however, your supervisor will be notified of the leave request.