F200055 Parental Leave Primary Caregiver Certification

Parental Leave

Primary Caregiver Certification

Instructions:

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Information on Completing the Form

  • This form should be used by a Secondary Caregiver, whose spouse or domestic partner is not a WBG staff, and who wishes tobe designated as Primary Caregiver after they have exhausted their Secondary Caregiver leave.
  • Please complete the form and discuss Primary Caregiver Certification with your manager.
  • Please submit parental leave request in LARS upon your manager’s approval of Primary Caregiver Certification.
  • Please email manager’s LARS email approval and attach the completed Primary Caregiver Certification Form to your LARS coordinator and HR Operations with the subject line: Primary Caregiver Certification

Please return this form to the HR Operations via (Please select one transmittal format, and submit only once):

1. Email at hroperations@worldbank.org

2. Fax (202) 522-7026

3. Interoffice mail, MSN MC3-300

Need Help? 

If you are experiencing any issues, please contact HR Operations via email: hroperations@worldbank.org  or phone 202-473-2222 or 5220+32222.

Revision 16 Oct 2024

Staff Information

World Bank Group UPI*

First Name*

Last Name*

Date of eligible life event (child birth /adoption)*

Staff Declaration

A Primary Caregiver is the parent who is the sole caregiver of the child during the majority of business hours throughout the period of Parental Leave requested.

I certify that I meet the following requirements under the WBG Parental Leave Policy:

1.  I am the biological parent or new adoptive parent.

2. I will be the Primary Caregiver during my additional WBG Parental Leave.

3. My Spouse/Domestic partner*

is either (i) returning to work prior to or as of the date. I commence my additional Parental Leave or has already returned to work (Complete Annex A) or (ii) deemed medically incapable of acting as Primary Caregiver (Complete Annex B).

Comments

I hereby certify that the information I have provided above is accurate and complete. I understand that any falsification or misrepresentation of information or my status as Primary Caregiver can result in disciplinary action under Staff Rule 3.00. I understand that all Parental Leave, including any sick leave taken in connection with Parental Leave, must be completed within one year after the birth or adoption.

WBG Staff Signature

Date

Spouse/Domestic Partner Signature

Date

Annex A: Completed by your Spouse/Domestic Partner’s Employer

This is to confirm that*

has returned/is expected to return to work on*

Employer Name*

Date

Manager Name*

Signature

Address*

Phone No*

Annex B: Completed by your Spouse/ Domestic Partner’s Physician

Based on my recent medical assessment*

is not capable of acting as the Primary Caregiver for the child due to postpartum illness or disability.

The expected duration of the medical illness or disability is*

Medical Practice Name*

Date

Physician Name*

Signature

Address*

Phone No*

After filling this document, you must sign and date it before returning this document to the World Bank Group. Please ensure ALL information in the submission form is complete and accurate before printing the form. This will generate your form(s) as a PDF file. Review the file for accuracy and completeness. If there is an error, please start a new form.