Pregnancy / Parental /Adoption Leave
Information Request Form

 

This form is intended to be used to request information on your eligibility for leave and Supplemental Employment Insurance Benefits (SEIB) from Western.  It will also allow Human Resources to help you plan and prepare for your leave.  Please note: all information provided will remain confidential.

There are a number of factors that impact your eligibility for leave and benefits including the length of time you have worked at Western, your employee group collective agreement, and your employment status with Western. Please provide answers to as many of the questions as you can in the form below.  A Western Human Resources Benefits Consultant will determine your eligibility and contact you with the information you will need to plan and apply for your leave.

If you are not ready to plan your leave but just have a question or two, please email your questions to hrhelp@uwo.ca.

CONTACT INFORMATION
First name
Last name
Employee Number
Department / Faculty
Preferred Phone Number
Preferred Email Address
   

SIGNIFICANT DATES

> Date the baby was born / is expected to be born / custody date (if adopting)
 
    mm/dd/yyyy  
   

> Date of your last work day before starting leave
 
    mm/dd/yyyy  
   

> Date you plan to return to work
 
    mm/dd/yyyy  
   

OTHER INFORMATION

> Are you planning to use vacation at the end of your leave?     No Yes

> Do you have a spouse working at Western?     No Yes

          If Yes, provide their Employee Number

> Will your spouse be applying for EI benefits?    No Yes

> Have you given notice to your Department/Faculty regarding your plans for leave?     No Yes

> Comments
   

The above information will be received by a Western Human Resources Benefits Consultant who will contact you with the information you will need to plan and apply for your leave. You will receive an acknowledgment message when you submit this form.

To verify that you are a real person and not an automated spam service, please check the box before hitting Submit...

 

This website is provided for information and planning purposes for Western employees only.  While every effort has been made to ensure its accuracy, if any conflict exists between the information on this website and the provisions of the various collective agreements or applicable legislation, the collective agreements or legislation prevail.

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