Request For Family/medical Leave Of Absence Form printable pdf download

Request for Family/Medical Leave of Absence

Name________________________Department________________________

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.

Sick_____Personal_____Vacation_____Compensatory_____Unpaid_____

You will receive a letter from the Benefits Office approving or denying your leave and

advising you of your rights for benefit continuation.

Signature______________________________Date_________

Supervisor’s Signature____________________Date_________

Unit Head Signature______________________Date_________

12/22/11

Request For Family/medical Leave Of Absence Form