BUMG Lactation Support Benefit Form

Instructions to Employee: Please complete all applicable fields. If during the duration of this benefit you anticipate taking time off (PTO or leaves of absence) greater than one week please fill out section 1A. This form should be submitted to your Administrative Director as early as possible but generally at least 2 months in advance of anticipated time of use. Once you have completed this form, your Administrative Director will get a notification to review and follow up with you.


Click here to view the Lactation Support guidelines or the FAQ.

 

SECTION 1: EMPLOYEE INFORMATION AND ATTESTATION

 
 
 
 
 
 
 
mm/dd/yyyy
 
 
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SECTION 1A: ANTICIPATED TIME OFF (GREATER THAN 1 WEEK) - PTO OR LEAVES OF ABSENCE*

*Please note: This is not an official time off request. Please follow any BUMG or Department specific policies for requesting time off or leaves of absence.

 

Please select the type of time off you anticipate to take during this benefit.

 
 
  1. I understand that this is a request for financial support only for lactation breaks at work.
  2. I understand that the paid lactation breaks period(s) will begin on the agreed-to start date(s) and will end after 6 months of total use, the child’s first birthday, or an earlier date I notify the Administrative Director, whichever is sooner.
  3. I understand that I am responsible for notifying my Administrative Director and Department Chair in writing of my start and end dates and I will notify them of any changes to these dates.
  4. I understand by selecting the checkbox below I am providing my electronic signature.