University of Leicester

Maternity LeaveForm (2 pages)

To be submitted no later than 15 weeks before the Expected Week of Childbirth

HR is happy to provide advice on the Maternity Policy & Procedure.

You may find it helpful to contact a member of HR before completing this form (Tel: 0116 252 2439).

Name: / Please print / Dept: / Please print

To HR:

Please accept this Form as notification of my intention to take Maternity Leave.

Please complete the relevant sections below. All members of staff must ensure Section D is completed.

SECTION A – CONFIRMATION OF MATERNITY LEAVE DATES

Please tick as appropriate:

I enclose my MATB1 form (Maternity Certificate) / I will submit the MATB1 form (Maternity Certificate) as soon as it is issued. (I understand that some dates may be subject to change once my MATB1 form has been issued)
My baby is due on: / //
I intend to start Maternity Leave on (normally a Monday): / //

SECTION B – CONFIRMATION OF RETURN TO WORK

The University will assume that you will take the full 52 weeks to which you are entitled, unless you inform us otherwise (giving at least 8 week’s notice of your return to work date).

Please tick to indicate whether you will be returning to work with the University at the end of your Maternity Leave:

Yes
No / If 'No', please complete Section C
If you intend to return to work before the end of your full 52 week Maternity Leave entitlement, you may wish to indicate your return date here: / //
If your anticipated return to work date should change, you must inform your manager in writing at least 8 weeks in advance of the change.

If you do not indicate your return date on this form, you will need to write to your line manager no later than 8 weeks in advance of your return date.

I understand that the University may reclaim the whole or part of the non-statutory element of maternity pay if I do not return to work and continue in employment for at least three months.

Your Signature: / Date: / //

PTO

SECTION C – CONFIRMATION OF RESIGNATION

I confirm that I do not wish to return to work with the University at the end of my Maternity Leave.

Therefore, I will be resigning from my post with effect from / //
Your
Signature / Date / //

Please note that your resignation can take effect from any date of your choice, including the end of your maternity leave period. You must give at least the period of notice required by your contract of employment.

Where you have indicated that you are not returning to work with the University at the end of your Maternity Leave, you will not be eligible for enhanced University maternity pay.

SECTION D – LINE MANAGER CONFIRMATION

Risk Assessment – New and Expectant Mothers at Work

To the Line Manager:

It is your responsibility to ensure that a risk assessment of the pregnant member of staff is undertaken in a timely manner by the relevant departmental Health and Safety Representative. The University has Health & Safety obligations that may require you to take action.

See the guidance document provided by Safety Services: New and Expectant Mothers at Work which may be downloaded from

I confirm that the Head of Department has been made aware of the above notification of Maternity Leave, and that a risk assessment has been undertaken.

PLEASE ENCLOSE A COPY OF THE RISK ASSESSMENT WHEN SUBMITTING THIS FORM.

Line Manager
Signature / Date / //
Print Name

Please return the completed form, plus the maternity risk assessment, to HR