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
First and Last
*
9 digits
*
xxx-xxx-xxxx
*
*
*
Leave request details
Reason for requesting leave

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

*
Signature

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

*
mm/dd/yyyy
*
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