Paid parental leave request form

Before you fill out the form, the following must already have occurred:

You read about the paid parental leave program.
You submitted the leave of absence request form.
Your short-term disability claim is approved by The Standard unless you are not filing a short-term disability claim.
You have documentation verifying your child's date of birth or proof of petition for the adoption.

After submitting your request, you'll receive confirmation by email. If you don't receive the confirmation email, contact hr.lam.office@hennepin.us.

Employee information

Name

First and Last

Employee ID number

9 digits

Personal phone number

xxx-xxx-xxxx

Personal email address

Supervisor's name

Leave request details

Reason for requesting leave

Birth of a child
Adoption of a child

Child's date of birth or adoption
Birth or adoption must already have occurred. Do not put in a future date.

Leave of absence start date

Has short-term disability claim been approved by the insurance carrier?

Yes
I'm not filing a short-term disability claim.

Signature

By typing my name below, I am electronically signing this request form.

Employee signature

Today's date

mm/dd/yyyy