Japanese to English Bus/Financial Human Resources

Hi guys. From what I can tell, this is a form that must be submitted to the public employment office ('Hello Work') in order to receive childcare leave benefits (the childcare in question being the leave of absence that the employee requests after finishing the maternity leave period they are granted by law). More about the system here: http://www.hellowork.go.jp/html/info_1_h3d.html

Hoping that someone has come across this before. If not, I will just have a go and create some approximate term! Thanks in advance.