Laserfiche WebLink
<br />PLEASE RETURN THIS FORM TO YOUR SUPERVISOR/MANAGER AND HR PERSONNEL AT LEAST 10 BUSINESS DAYS BEFORE <br />YOUR ANTICIPATED RETURN FROM CHILD BONDING LEAVE. <br /> <br /> NEW REQUEST REQUEST FOR ALTERATION <br /> <br />Name: Emp ID#: <br />Address: City: State: Zip: <br /> <br />Contact No.: Personal Email: Dept.: <br />Supervisor: Employees Status: Regular Non-Regular <br />Birthdate of Child: / / <br />Start Date for Requested Accommodation: / / <br /> -OR- <br />Requested Number of Breaks per Day: <br />First Lactation Break Second Lactation Break Requested Start and End Time: Requested Start and End Time: <br /> : to : : to : <br />Third Lactation Break Fourth Lactation Break Requested Start and End Time: Requested Start and End Time: <br /> : to : : to : <br /> <br /> <br />Employee Signature Date <br /> <br />YOU MAY BE CONTACTED BEFORE YOUR RETRUN TO WORK TO DISCUSS THE REQUESTED LACATION ACCOMMODATION AND ASSIST YOU IN TRANSITIONING BACK TO THE WORKPLACE AS A NURSING PARENT. <br />PRINT NAME/TITLE SIGNATURE DATE APPROVED <br /> (Employee’s Supervisor) <br /> <br /> (Human Resources) <br /> <br /> <br />I wish to use accrued: <br /> Sick Vac. Comp. <br /> DPL Mgmt. during my unpaid breaks. <br /> <br /> <br />The Department may provide a flexible <br />schedule, allowing you to make up unpaid <br />break time if it is feasible given the operational demands of the Department. <br /> I am requesting a schedule that will allow me to make up unpaid break time and work <br />the full amount of my regularly scheduled <br />hours.