Please read the Maternity/Adoption Policy and Procedure before completing this form.

On completion this form should be submitted to your HR Team with the following documentation:

  • Maternity Leave – MATB1 issued by your midwife
  • Adoption Leave – matching certificate or official notification of Adoption

Personal Details

TITLE:Preferred first name:Personnel no: ______

Forename(s):______Surname: ______

Academic/Service Unit: ______Email: ______

Home address (for communication to be sent to when you are on leave):

Paternity Leave and Pay

Indicate your length of service at the Qualifying Week / Maternity Leave and Pay / Adoption Leave and Pay / Indicate how many weeks leave you wish to take
1 or more years / 18 weeks Occupational Maternity/Adoption Pay
21 weeks of Statutory Maternity/Statutory Adoption Pay
13 weeks unpaid leave
26 weeks – less than 1 year / 6 weeks at 90% of salary
33 weeks of Statutory Maternity/Statutory Adoption Pay
13 weeks unpaid leave
Less than 26 weeks service / Employees may be eligible for Maternity Allowance / No entitlement to Statutory Adoption Pay.
You should contact your local council to determine if you are entitled to any other help.
What date do you want your Maternity/Adoption Leave to start?

Declaration

I have read and understand the Maternity/Adoption Policy and Procedure.
I will comply with the required timescales for Leave arrangements.
If in receipt of Occupational Pay I understand I must return to work for one month following leave or I will repay/have deducted from my final salary pay received beyond the statutory entitlement.
If taking Adoption Leave I confirm I have/will not take paternity leave and pay.
I have agreed with my manager when I will take annual leave prior to and/or following Maternity/Adoption Leave
Signed: Date:

If you do not intend to return to work following leave please refer to the resignation guidance.

Confirmation by Line Manager

I confirm I have discussed the employee’s plans and arrangements for leave and have/will discuss communication arrangements and Keeping in Touch days prior to the employee starting leave.
I confirm I have notified the Head of Unit of the employee’s leave.
Signed: Date: