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Maternity leave form template

A maternity leave form template is a standardized document that employees use to request time off for maternity-related reasons. It typically includes sections for personal information, expected dates of leave, and may require medical documentation. This template streamlines the process for both employees and employers to manage maternity leave requests efficiently.

A maternity leave form or paid parental leave (PPL) is an integral component of a comprehensive maternity leave policy within an organization. This document serves as the formalized request process for employees seeking time off due to pregnancy and childbirth.

Typically aligned with legal and company regulations, the form outlines necessary details such as anticipated start and end dates, any medical documentation requirements, and contact information.

The maternity leave policy, of which the form is a key element, ensures a structured and equitable approach to managing maternity-related absences, promoting transparency and consistency in the workplace while supporting the well-being of expectant and new mothers.

What should a maternity leave form include?

The Paid Parental Leave (PPL) Request Form is an essential tool for securing this precious time. Here’s a breakdown of what you need to know and fill out, according to U.S. Department of Commerce:

Identifying information

Employee name: Your full name as it appears in your employment records.
Contact details: Both personal and work phone numbers and email addresses.
Organization details: The specific name of your agency, office, division, branch, etc.

Plans for using paid parental leave

The heart of this form revolves around how you plan to use your PPL in conjunction with the Family and Medical Leave Act (FMLA).

Reason for FMLA Leave: Indicate whether it’s due to the birth of a child, adoption, or foster care placement.
Key Dates: Provide the anticipated or actual date of the child’s birth or placement, the start and end dates for using PPL, and your planned return-to-duty date after using other types of leave.

Requested method of using PPL

Continuous or intermittent use: Specify if you prefer to use PPL continuously or intermittently. For intermittent use, describe the reasons and plans.

Employee certifications

This section is crucial as it involves legal attestations and certifications.

Parental role: Confirm that the PPL is for fulfilling your parental role.
Documentation: Agree to provide necessary documentation as required.
Acknowledgment of consequences: Understand and acknowledge the consequences of providing false information.
Notification of actual dates: If you’ve provided an anticipated date, agree to notify your agency of the actual date as soon as possible.
Work obligation agreement: Attest to entering into the required work obligation agreement.
Truthful certification: Certify that all statements made in the form are true and correct.

Final Step: Employee’s Signature

Don’t forget to sign and date the form to validate your request.

Maternity leave form template

1. Identifying Information

Employee Name:
Phone Numbers:
Personal: [Your Personal Phone Number]
Work: [Your Work Phone Number]
Email Addresses:
Personal: [Your Personal Email Address]
Work: [Your Work Email Address]
Name of Organization: [Agency, Office, Division, Branch, etc.]

2. Plans for Substituting Paid Parental Leave (PPL) for FMLA Leave

Reason for FMLA Leave:
Birth of a Child
Placement for Adoption
Foster Care Placement
Date of Birth or Placement:
Anticipated: [Date]
Actual: [Date]
Date Use of PPL Begins: [Date]
Date Use of PPL Concludes: [Date]
Date of Planned Return to Duty: [Date]

3. Requested Method of Using PPL

Continuous Use
Intermittent Use
Reason(s) for Intermittent Leave: [Describe Reasons]
Plans for Using PPL on an Intermittent Basis: [Describe Plans]

4. Employee Certifications

I attest that PPL is being taken because of the birth of my child or because of placement of a child with me for adoption or foster care and that the PPL will be used in connection with my fulfillment of my parental role to care for and bond with the child.

I will provide documentation to support this request, as directed by my agency.

I acknowledge and understand the consequences of providing a false certification (e.g., the possibility that my agency could pursue appropriate disciplinary action, up to and including removal from Federal Service, or make a referral to a Federal entity that investigates whether conduct constitutes a criminal violation).

If I provided an anticipated date of birth or placement, I will notify my agency as soon as practicable of the actual date.

I attest that I am entering into the required work obligation agreement.

I hereby certify that all statements made in this application are true and correct to the best of my knowledge and belief.

Employee’s Signature: __________________________

Date: _________________________

Frequently asked questions

Related Company Policies

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