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1
Graduate Student Parental Leave Academic and/or Employment Accommodation Application
Graduate students requesting academic and/or employment accommodation should submit this completed form to their
graduate program, employing unit, and the Graduate School four months prior to the anticipated delivery date or
placement date, if the child(ren) is to be welcomed through adoption or foster care. If four months’ notice is not possible
under the circumstances, the form should be submitted as soon as possible.
This form is designed to coordinate with the “Academic Accommodation and Leave for Pregnant and Parenting Graduate
Students” and the “Employment Accommodation and Leave for Pregnant and Parenting Graduate Students,” collectively
referenced as the “Policy.” Nothing on this form shall be construed to contradict that Policy, as the Policy’s terms
supersede any conflicting terms on this form. Please review the Policy (https://www.k-state.edu/grad/graduate-
handbook/chapter1.html) prior to submitting this form.
Please note that any employee eligible for FMLA leave may seek leave to the extent permitted by that law, as set forth in
the University PPM, http://www.k-state.edu/policies/ppm/4800/4860.html#40a. Please contact Human Capital Services
Benefits (benefits@ksu.edu, 785-532-6277) with questions about FMLA leave and for the required FMLA leave forms.
For graduate students on an assistantship (GTA/GRA/GA), please discuss your anticipated employment duties, if any, and
stipend right away with your mentor, supervisor, and department head. Please first review the Employment
Accommodation and Leave for Pregnant and Parenting Graduate Students policy and submit this application form as soon
as possible, preferably four months prior to requested leave time.
Information for graduate student applying for accommodation:
First and last name:
Wildcat ID number (WID):
Graduate program and degree level:
Anticipated leave dates:
Accommodation begins the day of the date of birth, or initial placement related to adoption or guardianship event.
Assistantship Status:
GTA
GRA
GA
Combination
None
If you are a GTA/GRA/GA (or some combination), please indicate if you are seeking financial assistance during your
leave, such that you receive an equivalent amount of your stipend during your leave, as further set out in and as limited by
the Employment Accommodation and Leave for Pregnant and Parenting Graduate Students Policy.
Are you request continued stipend funding during your leave dates? Yes No
Is the other parent of the child(ren) a graduate student at K-State? Yes No
If you answered “yes” above:
Provide the name of the other parent:
Is the other parent requesting parental leave to care for the child(ren)? Yes No
Is the other parent requesting continued stipend funding during his or her leave? Yes No
Note: If both parents are requesting continued stipend funding while on parental leave, the parents are limited to a
combined total of six weeks of funding, as set out in the Policy.
Required Documentation:
2
1. Provide a letter from your healthcare provider stating the anticipated dates of absence and date of birth. If for
adoption or guardianship, provide substantiated documentation for anticipated dates of absence and date of
custody. This can be a letter from the social worker or other official knowledgeable of the placement.
2. Provide an Academic Accommodation Plan that describes the type of academic engagement, progress
expected, if any, during the leave period, and revised academic schedule for completing courses or research.
You are not required to engage in academic activities during your planned leave nor make progress unless
you explicitly request to do so and you have coordinated that request with your major professor and
department head or graduate program director.
3. If you are a GTA/GRA/GA, provide a Modified Employment Plan that describes the type of employment
responsibilities, progress expected, if any, during the leave period, and revised employment schedule for
completing assigned responsibilities. You are not required to engage in employment responsibilities during
your planned leave nor make progress unless you explicitly request to do so and it is agreeable to your major
professor, supervisor of assistantship, and department head or graduate program director.
By signing below, I confirm that the information provided in this form and accompanying documentation is accurate.
Graduate student name:
Signature:
Date:
By signing below, we agree with the student’s Academic and/or Employment Accommodation Plan, as applicable.
Major professor name:
Signature:
Date:
Department head or
graduate program director:
Signature:
Date:
Supervisor, if employing unit is not the student’s academic home:
Signature:
Date:
The student should submit this completed form with required documents to the Graduate School, 113-119
Eisenhower Hall. A copy of this form and supporting documents should be retained in the student’s academic
department and employing unit if requesting employment accommodation.
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Completed 21 August 2020

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