My leave plan worksheet
A printable from Pregnancy Leave and Pay. Fill it in by hand. Nothing you write is collected by this website.
My leave plan worksheet
Dates
- Due date: ____________
- Last day I plan to work: ____________
- Provider's estimate of time off after birth: ____ weeks
My employer
- Number of employees (5 or more?): ____
- Have I worked there 1 year and 1,250 hours? Yes / No
- Date I told my employer in writing: ____________
- Who I told: ____________
Pay claims
- Disability claim filed on: ________ (within 49 days)
- Claim number: ____________
- PFL form arrived on: ________
- PFL claim filed on: ________ (within 41 days)
Health insurance
- My employer will keep paying its share during leave
- My baby is added to my health plan or Medi-Cal
If my baby is in the NICU
- Hospital and unit: ____________
- Admission date: ________ Discharge date: ________
- Baby's doctor: ____________
- I called EDD or a clinic to ask which claim to file first
Return to work
- Planned return date: ____________
- I asked about a place and breaks to pump
From Pregnancy Leave and Pay. Facts checked October 21, 2026. Free information, not legal or medical advice.