Family Medical Leave/employee Leave Request Form - Seton Hall University Page 2
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1
2 A qualifying exigency arising out of active duty or notification of impending call to order to active duty in
the armed forces in support of a contingency operation of:
o Spouse
Name: ______________________________________________
o Child
Name: ______________________________________________
o Parent
Name:______________________________________________
Recovery from a serious injury or illness suffered while on active duty in the armed forces of:
o Spouse
Name: ______________________________________________
o Child
Name: ______________________________________________
o Parent
Name:_______________________________________________
o Next of Kin
Name:_______________________________________________
I HAVE or HAVE NOT previously taken FMLA or NJFLA-protected leave for this reason [circle one].
DATES OF LEAVE REQUESTED:
I request leave from ________________________ to ______________________________.
I request intermittent leave according to the following schedule :__________________________
____________________________________________________________________________
____________________________________________________________________________
I request a reduced schedule leave according to the following schedule:____________________________
___________________________________________________________________________________
The total number of weeks/ days of leave that I request is ______________________________
EMPLOYEE STATEMENT
I certify that the statements made above are true and accurate. I understand that I have an obligation to respond to
any questions from the University designed to determine whether my absence is potentially FMLA and/or NJFLA
qualifying. Furthermore, I understand that if I fail to respond to any reasonable inquiry by my employer regarding
this leave request, the University may deny my leave request if the University is unable to determine whether the
leave is FMLA and/or NJFLA qualifying.
Signature:______________________________________________ Date:______________________________
Supervisor Approval
Supervisor Signature:
Date:
Comments:
HR Approval
HR Signature:
Date:
Comments:
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