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Leave & Time
Parental Leave Request Form
A form for employees to request maternity, paternity, or adoption leave with eligibility verification, expected dates, and benefits communication tracking.
PARENTAL LEAVE REQUEST FORM
EMPLOYEE INFORMATION
Name: [Full Name] | Employee ID: [Number]
Department: [Department] | Job Title: [Title]
Date of Request: [Date]
LEAVE DETAILS
Type: ☐ Maternity ☐ Paternity ☐ Adoption ☐ Parental
Expected/Actual Birth Date: [Date]
Expected/Actual Placement Date (adoption): [Date]
Leave Start: [Date]
Leave End: [Date]
Total Duration: [Weeks/Days]
Additional unpaid parental leave requested?: ☐ Yes — [Weeks/Days] ☐ No
SUPPORTING DOCUMENTS
☐ Medical certificate (for maternity/medical)
☐ Adoption placement documentation
☐ Birth certificate (to be provided after birth)
ACKNOWLEDGMENT
I understand:
• Statutory benefits administered per applicable law.
• My role or equivalent will be held during absence.
• Health coverage continues during leave.
• I will be contacted before return to plan reintegration.
• I may use accrued annual leave to extend paid time off.
Signature: _______________________ Date: _______________________
HR USE
Eligibility verified: ☐ Yes — [Number] months service
Benefits communicated: ☐ Yes — on [Date]
Leave recorded: ☐ Yes — on [Date]
☐ Maternity benefits initiated | ☐ Paternity approved | ☐ Adoption approved
Expected return: [Date] | Return-to-work meeting: ☐ Scheduled [Date] ☐ Pending
Approved by: [HR Name] | Date: [Date]