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

After you complete the form

For submitting proof of your child's birth or adoption to complete your request, you must follow the instructions that will be emailed to you.

The document must include the employee's name and the child's date of birth. You may submit the hospital birth record. The document does not need to be a certified birth certificate.

For adoption, show proof that a petition of adoption has been filed with the court.

Please block out your social security numbers and mailing address.

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

Please check one of the following:

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?

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

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

Signature

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

Employee signature

Today's date

mm/dd/yyyy