Questionnaire - FASTER DRAFT

Who is Employee?

Indicate an Employee's full name (i.e. this a person who wants to request a maternity leave):

!
Maternity leave is a period of authorized time off from work granted to an employee before or after the birth of a child.

In the U.S., it may be unpaid or paid depending on employer policy or respective state laws. There is no mandatory paid maternity leave at the federal level.
Indicate an Employee's full residential address:
Indicate an Employee's current job title:
Indicate an Employee's personal email address:

!
This email address can be used by the employer in order to reach an employee during their maternity leave.

Therefore, only a personal email (not the working one) should be provided as the answer to this question.

Who is Employer?

The Employer is:
- A business or organization
- An individual
Indicate an Employer's full name:
Indicate the Employer's company full name:
Indicate an Employer's full address:
Indicate a name of a person to whom this letter will be addressed:

!
This is usually a name of a company’s CEO or head of HR department who is in charge of employees’ maternity leave requests.

About the Request

Which type of maternity leave does an Employee want to request?
- defined by the company's internal policies
- defined by the Family and Medical Leave Act
- defined by the applicable state laws
The requested maternity leave should be:
Select the date when a maternity leave STARTS:
An Employee plans to take a maternity leave:
- in a continues block without interruption
- in installments
Select the date when a maternity leave ENDS:
Describe in detail the schedule according to which an Employee plans to take days of maternity leave:

Miscellaneous

Indicate the total number of days of maternity leave an Employee plans to take:
Select the date on which an Employee signs this letter:
Select the date on which an Employee plans to resume their regular duties:
Does an Employee wish to offer a transition plan of their duties and responsibilities for the period of their absence?
- No
- Yes
!
An Employee may offer to assist in a handover plan, including task delegation and training of a temporary replacement, if needed.
Does an Employee have a COBRA coverage?
- No
- Yes
!
COBRA coverage is continued insurance coverage that is being offered by some employers within the United States.

Do you want to add a signature?
- Yes
- No
Employee's signature:

Select a document's format:

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DOCX

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Who is Employee?

Indicate an Employee's full name (i.e. this a person who wants to request a maternity leave):

Indicate an Employee's full residential address:

Indicate an Employee's current job title:

Indicate an Employee's personal email address:

Who is Employer?

The Employer is:

Indicate an Employer's full name:

Indicate the Employer's company full name:

Indicate an Employer's full address:

Indicate a name of a person to whom this letter will be addressed:

About the Request

Which type of maternity leave does an Employee want to request?

The requested maternity leave should be:

Select the date when a maternity leave STARTS:

An Employee plans to take a maternity leave:

Select the date when a maternity leave ENDS:

Describe in detail the schedule according to which an Employee plans to take days of maternity leave:

Miscellaneous

Indicate the total number of days of maternity leave an Employee plans to take:

Select the date on which an Employee signs this letter:

Select the date on which an Employee plans to resume their regular duties:

Does an Employee wish to offer a transition plan of their duties and responsibilities for the period of their absence?

Does an Employee have a COBRA coverage?

Do you want to add a signature?

Employee's signature:

Select a document's format: