: Notice of intent to take paid parental leave, for a period not to exceed 8 consecutive weeks,
must be submitted to the department chair/unit head and to the Director of Human Resources at least 90
calendar days prior to the proposed date of the leave or when the employee has knowledge of the impending
birth or adoption, whichever occurs later. Applicant completes Part I of the form, obtains the signature of the
Chair/unit head (to indicate that he/she has been informed of the anticipated leave), and forwards the form to
the Human Resources Department (“HR”). HR completes Part II of the form, returns a copy to the applicant
and to the Chair/unit head, and places a copy in the applicant’s personal personnel file, in accordance with
standard procedures.
(To be completed by employee)
Name: ______________________________ College: _________________________________
Job Title: ____________________________ Department/Unit: __________________________
Home Address: _____________________________________________________________________
Phone: (h) ____________________ (o) _____________________ (cell) ______________________
Email: _______________________________________________________________
I hereby give notice of my intent to take paid parental leave. The expected date of the child’s birth or
placement for adoption is: __________________________. I anticipate taking _____ weeks of paid
parental leave commencing:
with the birth/placement for adoption; or
following the expiration of temporary disability leave taken to recover from childbirth
(for birth mothers only); or
from _________ to _________, in accordance with sub-section ______ of the Policy.
(Employees should review sub-sections 3.b, c, d and 4.a, b, c of the Paid Parental Leave Policy.)
I request the following modification and understand that my request is subject to approval and will
require a written agreement:
(Contact HR to facilitate this process.)
I understand that the following conditions apply to this leave:
The Paid Parental Leave Policy is available on the University’s website.
The period of the leave counts as service for purposes of tenure, a Certificate of Continuous
Employment, a Certificate of Continual Administrative Services (“13.3b”), and the five-year limit
on Instructor service, unless the employee submits an irrevocable written election to his/her
Chair/unit head and the HR Director, within 90 days following the birth or placement for
adoption, to have the period of leave serve as a bridge. (Contact HR for the applicable form and
to determine eligibility, in accordance with section 6 of the Policy.)
The period of the leave runs concurrently with Family and Medical Leave Act (“FMLA”) leave,
to the extent that such leave is available to the employee. The application for paid parental leave,
accordingly, serves simultaneously as an application for FMLA leave.
For members of the teaching faculty: If the faculty member’s leave expires mid-semester, he/she
may return either to teach or to administrative duties for the balance of the semester, at the
discretion of, and as assigned by, the department chair after consultation with the employee.
(Note: Faculty members are encouraged to discuss scheduling issues with their department chairs
in advance of the anticipated leave.)
I understand that I will be required to submit proof of my child’s birth or proof of the formal placement with
me of a child for adoption and proof of said child’s age.
Signature: __________________________________ Date: _________________________________
I have been informed of the anticipated leave. I approve do not approve of the modification requested
above; or, none requested.
Signature: __________________________________ Date: _________________________________
(Department Chair/Unit Head)
(To be completed by Human Resources)
Applicant meets one-year service requirement: _____________________________________________
(Enter start date of applicant’s full-time CUNY employment)
Proof of Birth/Placement for Adoption: _____________________________________________________
(Specify documentation submitted)
Age of child placed for adoption: _________
Period of Temporary Disability Leave
(for birth mother): From _____________ To ____________ ; or
Period of Paid Parental Leave: From _____________ To ______________
Period of FMLA Leave (concurrent with above two periods, to the extent available): From _______ To _______; or
None Available to Applicant
Description of modification approved (if any), pending written agreement:
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Inadequate/Incomplete Documentation
Requested Modification Denied
Signature: ______________________________________ Date:________________________________
(Human Resources Director)
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