Request For Leave With Or Without Pay - Department Of Corrections
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1
2DEPARTMENT OF CORRECTIONS
REQUEST FOR LEAVE WITH OR WITHOUT PAY
THIS FORM MUST BE COMPLETED AND SIGNED BY EMPLOYEE AND, IF APPLICABLE, CERTIFICATION OF HEALTH
CARE PROVIDER MUST ALSO BE COMPLETED AND ATTACHED, BEFORE FORWARDING TO SUPERVISOR FOR
APPROVAL. A COPY OF THE REQUESTING EMPLOYEES TALRS PRORATION SCREEN MUST ALSO BE ATTACHED.
PART A
GENERAL INFORMATION
NAME______________________________________________TITLE_________________________________________________
ADDRESS_______________________________________________________HOME PHONE_____________________________
DIVISION/BUREAU/INSTITUTION_____________________________________________________________________________
PART B
TYPE OF LEAVE REQUESTED
I HEREBY REQUEST A LEAVE OF ABSENCE DUE TO:
FAMILY LEAVE, IF I MEET ELIGIBILITY REQUIREMENTS AS STATED IN HRB 96-01, FOR THE FOLLOWING QUALIFYING
EVENT. COMPLETED CERTIFICATION OF HEALTH CARE PROVIDER MUST BE SUBMITTTED WITH ALL MEDICAL LEAVE
REQUESTS.
PERSONAL ILLNESS*
SERIOUS HEALTH CONDITION OF FAMILY MEMBER
RELATIONSHIP____________________________
PREGNANCY DISABILITY
BIRTH OF CHILD
LEAVE OF ABSENCE WITH WORKERS COMPENSATION
INDICATE DATE OF BIRTH__________________
SLI/ON THE JOB INJURY
PLACEMENT OF A CHILD DUE TO ADOPTION OR
ATTACH COMPLETED ACCIDENT REPORT (RM-2)
FOSTER CARE - DATE_____________________
SUBMITTED NO LATER THAN THE 2ND DAY AFTER
THE INJURY OR ILLNESS OCCURRED, IN TRIPLICATE,
CHILD CARE
TO THE PERSONNEL OFFICE.
VOLUNTARY FURLOUGH
MILITARY - ATTACH COPY OF ORDERS
VOLUNTARY FURLOUGH EXTENSION
OTHER____________________________
INITIAL REQUEST
EXTENSION REQUEST
DOES YOUR SPOUSE WORK FOR THE STATE OF NJ?
YES
NO IF YES, INDICATE NAME & DEPARTMENT ________________________________________________
I HEREBY REQUEST THAT THIS LEAVE BE
WITH PAY
WITHOUT PAY.
*Any employee on leave due to stress or psychological and/or related conditions must be cleared by a psychiatrist or
licensed clinical psychologist prior to returning to work. Questions regarding this policy may be directed to your HR
Manager.
SIGNATURE______________________________________________________
DATE_______________________________
PART C
DURATION OF LEAVE
TO BE COMPLETED FOR ALL TYPES OF LEAVE REQUESTS
FULL TIME LEAVE FROM______________________THROUGH_______________________
REDUCED OR INTERMITTENT LEAVE - ATTACH DETAILED SCHEDULE
DEPARTMENT POLICY REQUIRES THE USE OF ALL EARNED SICK LEAVE PRIOR TO RECEIVING A LEAVE WITHOUT
PAY.
DO YOU WISH YOUR EARNED VACATION TIME TO BE USED?
YES
NO
DO YOU WISH YOUR EARNED COMP TIME TO BE USED?
YES
NO
(WILL NOT REDUCE FAMILY LEAVE
ENTITLEMENT)
DO YOU WISH YOUR EARNED AL TIME TO BE USED?
YES
NO
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