Paternity Leave
Application Form HR 108 (k1)
This form is to be used by employees wishing to apply for Paternity Leave and should be
submitted 4 weeks prior to commencement of leave.
Please complete in Block Capitals/Tick appropriate boxes.
HR 108 (k) V3 1st Sept 2016 Page 1 of 2 Revised 01/09/2016
Section 1. To be completed by the employee
Surname:
First Name:
Grade:
Personnel No:
Location:
PPS No:
I hereby notify my employer that I intend to take Paternity Leave in accordance with the provisions of the Paternity
Leave and Benefit Act 2016
Expected date of confinement or date of birth
Expected date of adoption placement or date of adoption
Paternity
leave start
date
Paternity
leave end
date
Signature:
Date
Section 2. To be completed by the employee
Please indicate how you are the “relevant parent” (tick the appropriate box).
The father of the child
The spouse, civil partner or cohabitant of the mother of the child regardless of gender
A parent of the child as defined under Section 5 of the Children and Family Relationships Act 2015
In the case of a child who is adopted the leave will apply to:
A person (other than the mother of the child) who is the spouse, civil partner or cohabitant of the adopting
mother or sole male adopter of the child
Where the child is adopted jointly by a married couple of the same sex, the spouse chosen by that couple to
be the relevant parent for the purposes of Paternity Leave and Benefit
Section 3. Check List
Please ensure you submit the relevant Documentation with your application (please refer to exp. note)
Copy of the medical certificate signed by a registered medical practitioner confirming the pregnancy of the
expectant mother and specifying the expected week of confinement
Copy of the birth certificate
Copy of certificate of placement (adoption)
Particulars in writing of the placement (intercountry adoption)
Copy of an applicable declaration of eligibility and suitability (intercountry adoption)
Paternity Leave
Application Form HR 108 (k1)
This form is to be used by employees wishing to apply for Paternity Leave and should be
submitted 4 weeks prior to commencement of leave.
Please complete in Block Capitals/Tick appropriate boxes.
HR 108 (k) V3 1
st
Sept 2016 Page 2 of 2 Revised 01/09/2016
Section 4. To be completed by the Line Manager
I have checked the details and documentation provided by the employee and confirm that the employee is eligible
to take paternity leave in accordance with the Act of 2016.
Signature:
Date
Name:
Grade:
Contact Phone Number:
Mobile No:
Email Address:
Section 5. Delegated Officer Aproval
Name (Print)
Signature
Tel No.
Date
Decision No.
Section 6. To be completed by Human Resourses Personnel Adminstration
System updated by:
Signature
Tel No
date
Comments
Section 7. Circulation List
1
2
3
4
5
6
7
8
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