Request For Family/medical Leave Of Absence Form


Request for Family/Medical Leave of Absence
Date of Hire___________________Supervisor_________________________
Phone Number Where you can be Reached While on Leave_______________
I am requesting a family/medical leave of absence. All requests must be submitted to
the Benefits Office 30 days prior to the start of leave or as soon as foreseeable.
Qualifying Event (Please check one)
Please note that the events below are the only events that qualify for leave under
Federal (FMLA) or NJ State law (FLA). If the leave is not for one of these events, it will
be handled as a personal leave of absence and not subject to the provisions of Federal
(FMLA) or NJ State law (FLA). Please note that personal illness or family illness
requires medical certification, which should be given only to the Benefits Office.
Personal Illness______________(FMLA only
Care of a seriously ill family member_____ Relation to employee_________________
(Child, spouse, parent, parent-in-law)
Birth or adoption of child________ Anticipated date of birth_____________________
Duration of Leave
Date Leave Begins_______________Anticipated Return to Work date____________
Intermittent Leave
Intermittent leave is only permitted for personal illness for yourself or a covered family
member. In the event that you request intermittent leave, it should be scheduled so as
not to unduly disrupt operations of the College. If you are requesting intermittent leave
please indicate the proposed schedule of absences:
Please indicate which accruals we are allowed to charge if you wish to remain in
pay status while on leave.
You will receive a letter from the Benefits Office approving or denying your leave and
advising you of your rights for benefit continuation.
Supervisor’s Signature____________________Date_________
Unit Head Signature______________________Date_________


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