Parental Bereavement Leave and Pay Form	HR57

Employees are entitled to two weeks of paid parental bereavement leave if their child or a child in their care has died or been stillborn after 24 weeks of pregnancy.  Leave can be taken in blocks of one week, two consecutive weeks, or two separate weeks.  It can be taken at any time during the first 56 weeks after the child’s death. Parental Bereavement Pay includes any entitlement to statutory parental bereavement pay for that week.  

In the first eight weeks after a child has died, there is no requirement to give advance notice to take parental bereavement leave. Employees should notify their line manager as soon as they can on the day they want their leave to start, where possible, before the time they would normally start work. To take parental bereavement leave more than eight weeks after the child has died, employees should give at least a week’s notice.

Employees should complete this form within 28 days of starting any period of parental bereavement leave, in order that leave can be properly recorded.

If you have any questions or you need more information about available support, please contact your HR Business Manager for advice. You are also advised to read the Parental Bereavement Leave and Pay Policy and Procedure before completing this form. 

PART 1 –  details of leave and application for pay
To be completed by the employee
Section A – Personal Details and employment
These questions must all be answered.  Your personal reference number can be found on your payslip. 

Questions 6 and 7: it is very important that we know what days of the week you are working in order that we can calculate your leave entitlement correctly. In question 7, tell us the start date of this pattern (even if in the past).  If your pattern changes before you go on leave, you must tell us.	1. Surname	

2. Forenames	

3. Personal Reference Number	

	

	

4. Position Held	

5. Faculty / Department 	

6. Working pattern
Every weekday Monday-Friday	

Specified below	

Mon	
	
Tue	
	
Wed	
	
Thu	
	
Fri	
	
Sat	
	
Sun	

7. Start date of this pattern (if known)	

	

	

	
Section B – Details of leave 

	8. Date of child’s death or stillbirth 	

	

	

9. Dates of leave taken	

	

	

Start Date	

	

	

Finish Date	

	

	

Start Date	

	

	

Finish Date	

	

	

Parental bereavement leave can be taken in blocks of one week, two consecutive weeks, or two separate weeks. It can be taken at any time during the first 56 weeks after the child’s death. 	

Section C – Declaration

The information included in this application is correct.

I declare that:

	Tick one	
I am the biological (or foster) parent, or their partner		
I am the adoptive parent, or their partner		
I am a surrogate parent, or their partner		
I am a parent, or the partner of a parent, who has used a surrogate		
I am the natural parent, or their partner, of a child who has since been adopted by someone else, and there is a court order allowing me or my partner to have contact with the child		
I or my partner provided day to day care to the child, other than as a paid carer, for the 4 weeks before their death		

Signed	(applicant)							Date				 

This form should now be sent to your Departmental Administrator

Part 2 – Institutional acknowledgement
To be completed by the institution

Leave approved (signature of Head of Institution or authorised deputy)

Signed  							Name						

Position  							Date						

This form should now be emailed to your HR Administration Team at the relevant address:

Lifeeventsandleave@admin.cam.ac.uk 		cshrstaffhub@admin.cam.ac.uk 
	
School of Arts & Humanities		School of Clinical Medicine	
School of the Biological Sciences			
School of the Humanities & Social Sciences			
School of the Physical Sciences
School of Technology 
UAS			
Non-School Institutions 			

An employee who is due to go on, or is currently taking parental bereavement leave, is entitled to access all of the usual support networks available to staff. This includes within their Department (e.g. Departmental Administrator), within HR (e.g. HR Business Manager/Adviser),the Occupational Health Service and Staff Counselling Service.
In addition, some relevant charities which may also be able to provide support and guidance in the circumstances:

•	https://www.childbereavementuk.org/
•	https://www.tcf.org.uk/content/ftb-grieving-parents/
•	https://www.careforthefamily.org.uk/family-life/bereavement-support/bereaved-parent-support
•	https://www.england.nhs.uk/publication/learning-from-deaths-information-for-families/
•	https://www.cruse.org.uk/
•	https://youngminds.org.uk/
•	https://www.cambridgeshire.gov.uk/residents/births-deaths-and-marriages/deaths/registering-a-death