Paid parental leave request form

When to complete the form

After the birth or adoption of your child
After you submit the leave of absence request form
After you read about paid parental leave
After your short-term disability claim is approved unless you're not filing a claim

You'll get email instructions for submitting proof of your child's birth or adoption

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