Parental Leave Notice

Parental Leave Notice

To provide notice of intent to use parental leave. 30-days notice.
• Complete this form to provide formal notice of your intent to use parental or postpartum recovery leave.
• Submit the completed form to the Human Resources Department at least 30 days before the start of leave.
• If circumstances prevent timely notice, submit the form as soon as practicable.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Employment Location
Select Leave Type:

Parental Leave - for bonding with child due to birth, adoption, etc. (Paternal, Adoption, etc. Leave)Postpartum Recovery Leave - for recovery following childbirth (Maternal Leave)
Event Type:

Birth of a ChildAdoption of a ChildLegal Guardianship of a ChildFoster Placement of a Child
Estimated Start Date

MonthDayYear
Date
Estimated End Date

MonthDayYear
Date
Are you a part-time employee requesting pro-rata leave?

YesNo
Acknowledgment and Signature

I certify that the information provided in this form is accurate to the best of my knowledge. I understand that parental or postpartum recovery leave will run concurrently with applicable Family and Medical Leave Act (FMLA) provisions.
Signature

Clear
Should be Empty: