Ucf-Human Resources - Parental Leave Request Form
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1
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3PARENTAL LEAVE REQUEST FORM
Please Print, Type or Write Legibly
Check one:
New Leave of Absence:
Revision of original request (superseding):
Extension of Leave:
Department Name: ______________________________________________College/Division: _____________________________________________________
Employee ID #:_________________________Position Title: _______________________________ Check one: USPS:
A&P:
Faculty:
OPS:
Employee’s Name: ___________________________________________________________________________________________________________________
Last name
First name
Middle Initial
Home Mailing Address: _______________________________________________________________________________________________________________
Street Address/P.O. Box
City
State
Zip
Home Email Address: ____________________________________________ Campus Email Address: ______________________________________________
Campus Phone #: __________________________ Home Phone #: ____________________________ Cell Phone#:__________________________________
Type of Leave:
Parental—Birth*:
Parental—Adoption**:
Foster Placement**:
*A UCF Certification of Health Care Provider Form for the birth mother must be submitted with this form.
**A copy of a Court or Agency document placing a child in your home is required when requesting parental leave for
the adoption of a child or the placement of a foster child in your home.
Last Day of Work: ____________________________
Start Date: ______________________________ End Date: ______________________________
I anticipate returning to my normal work schedule and duties on: Date: _________________________ Time: __________________________________
A Reduced Work Schedule Leave:
Combination of Paid and Unpaid Leave:
My leave will be: A Full Unpaid Leave:
A Paid Leave:
Note: A proposed work schedule must
be attached. For A&P and USPS, a
telecommuting agreement is required to
work from home.
In-Unit Paid Parental Leave:
While not working I will use accrued: Sick:
Annual:
Compensatory:
Leave Without Pay (LWO):
(Check all that apply)
Note: A completed Memo of
Understanding must be attached.
I understand
and accept a leave of absence as stated on this page. I further acknowledge that I have read the “Employee and Department Responsibilities for
understand
Completion” page accompanying this form and I
all of my leave responsibilities and the information provided therein:
Employee Signature: ______________________________________ Date: _____________________________________
For Use By Department and Human Resources
Department (Supervisor) must complete (Please type or print legibly):
Payroll Processor: ________________________________________________________email:______________________________________________________
ePAF Processor: __________________________________________________________email:______________________________________________________
HR Liaison: _____________________________________________________________email:_______________________________________________________
Approved
Yes:
No:
Signature Chair/Supervisor: ________________________________________________________ Date: _____________________________
Print Full Name: ______________________________________________________
Campus Extension: ____________________________
Email Address: ______________________________________________________________________________________________________
Signature Dean/Director: ________________________________________________________ Date: _____________________________
Yes:
No:
Print Full Name: ______________________________________________________
Campus Extension: ____________________________
Email Address: ______________________________________________________________________________________________________
Comments:____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
__ For HR Use Only
The Human Resources Director has Final Approval for all parental leaves of absence.
This request for leave of absence is approved:
YES:
NO:
Employee is on paid leave:
This leave counts toward the employee’s FMLA entitlement:
YES:
NO:
Employee is on unpaid leave:
During this leave the employee will use approximately _______________ weeks of their twelve (12) week FMLA entitlement and will have ____ weeks of
entitlement remaining for use in fiscal year ___________.
Human Resources Director: By: _______________________________________________________ Date: _______________________________________________
Comments:_____________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Revised Feb 2016
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