Form Pfl-1 And Pfl-2 - Paid Family Leave Forms Page 4
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10Request For Paid Family Leave
(Form PFL-1)
INSTRUCTIONS INCLUDED WITH FORM
PART A - EMPLOYEE INFORMATION (to be completed by the employee)
1. Employee’s legal name (first name, middle initial, last name)
Optional (for research purposes)
10. Employee’s ethnicity/race
Other last names, if any, under which employee has worked
2.
For purposes of health demographic only. (U.S. Centers for
Disease Control and Prevention (CDC) code set, version 1.0.)
Is employee of Hispanic, Latino/a, or Spanish origin?
3. Employee’s mailing address
(One or more categories may be selected.)
Street address
Mexican
Mexican American
City, State
Chicano/a
Puerto Rican
Zip code
Country (if not U.S.A.)
Dominican
Cuban
Another Hispanic, Latino/a, or Spanish origin
4. Employee’s Social Security Number or TIN
Not of Hispanic, Latino/a, or Spanish origin
-
-
Unknown
5. Employee’s date of birth (MM/DD/YYYY)
What is employee’s race?
(One or more categories may be selected.)
/
/
American Indian or Alaska Native
Black or African American
6. Employee’s primary telephone number
Asian Indian
(
)
-
Chinese
7. Employee’s preferred email address while on PFL (if available)
Filipino
Japanese
Korean
8. Employee’s gender
Vietnamese
Male
Female
Not designated/Other
Other Asian
White
9. Employee’s preferred language
Native Hawaiian
English
Español
Русский
Polski
Guamanian or Chamorro
中文
Italiano
Kreyòl ayisyen
한국어
Samoan
Other
Other Pacific Islander
Other race
Paid Family Leave (PFL) Request (to be completed by the employee)
Bond with child
Care for family member
Military qualifying event
11. Reason for PFL request:
12. The family member is employee’s:
Child
Spouse
Domestic partner
Parent
Parent-in-law
Grandparent
Grandchild
Form PFL-1 continued on next page
PFL-1 (10-17)
If you need assistance, please call (844) 337-6303
Page 1 of 4
PFL-1 10-17
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