PDF Version

Employee’s Notification of New Child in the Family

Family and Medical Leave Act of 1993 (FMLA)

Family and Medical Leave Act Rules:  New Child in the Family 

The Family and Medical Leave Act guarantees each worker 12 weeks of time off per year for the birth, adoption, or placement in foster care of a child; the employee can also use the leave to care for the child during the first year.  To take FMLA leave for a new child in the family, an employee must notify management within 30 days (when practicable) of the anticipated date of the birth, adoption, or foster care placement.  This form may be used for that purpose.

Employee Name (Print):____________________________________________________________

 

To Supervisor:

This serves as notification under the Family and Medical Leave Act of 1993 that I expect to become the parent of a new child, by (check one):

___ Birth

___ Adoption

___ Placement in foster care

on (approximate date):_________________________________________________________

Following that date I plan to take time off from work to care for my new child.  I plan to return to work on (approximate dates):_________________________________________________________

Employee Signature and Date:___________________________________________________________________