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

First and last name (required) Employee ID number (required)

This should be no longer than 9 digits.

Personal phone number (required)

Format as xxx-xxx-xxxx.

Personal email address (required) Confirm email (required) Supervisor's name (required)

Reason for requesting leave (required)

Birth of a child

Adoption of a child

Please check one of the following (required)

I am the birth parent.

I am the non-birth parent.

If you are the birth parent, has a short-term disability claim been approved by the insurance carrier? (required)

Yes

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

N/A

Child's date of birth or adoption (required)

Leave of absence start date (required)

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

Employee signature (required) Today's date (required)