Family Medical Leave/employee Leave Request Form - Seton Hall University
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FAMILY MEDICAL LEAVE
EMPLOYEE LEAVE REQUEST FORM
Employee Name:_______________________________________________________
___
SHU ID#:
Date:
Job Title:
Supervisor: __________________________
_
Eligible employees are entitled under the Family and Medical Leave Act (FMLA) and/or the New Jersey Family
Leave Act (NJFLA) for up to 12 weeks of unpaid, job-protected leave for certain family and medical reasons, and
up to 26 weeks of unpaid, job-protected leave in a 12-month period to care for a covered family member who was
seriously ill or injured during their active military service.
Submit this request form to you supervisor at least 30 days before the leave is to commence, when possible. When
submission of the request 30 days in advance is not possible, submit the request form as early as is possible. The
University reserves the right to delay or deny leave for failure to give appropriate notice when such delay/denial
would be permissible under federal or state law. Refer to the Family Medical Leaves Policy for complete details.
ELIGIBILITY
Counting any periods of time that you worked for the University (whether they were consecutive or not),
have you worked for the University for a total of 12 months or more?
Yes
No
During the past 12 months, have you worked at least 1,000 hours?
Yes
No
Have you previously received medical or family leave?
Yes
No
If yes, provide information below:
Date of leave: From ___________________________ To: ______________________________
Purpose of leave: ________________________________________________________________
______________________________________________________________________________
Have you taken any intermittent leave?
Yes
No
Have you taken time off from scheduled hours?
Yes
No
If “yes”, provide details: ____________________________________________________
REASONS FOR REQUESTING LEAVE:
I am requesting leave for the following reason [check one]:
My own serious health condition
Serious health condition of:
o Spouse
Name:______________________________________________
o Child
Name:______________________________________________
o Parent
Name:______________________________________________
Birth of Child
Expected delivery date is:________________________________
Adoption or placement of a child for foster care
o Child’s Name: ____________________________________________________
o Scheduled date of adoption or placement:_______________________________
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