Request For Leave With Or Without Pay - Department Of Corrections Page 2
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1
2PART D
VOLUNTARY FURLOUGH/FURLOUGH EXTENSION LEAVE
REASON FOR REQUEST_______________________________________________________________________
EMPLOYEE: READ CAREFULLY AND SIGN
I CERTIFY THAT I WILL NOT USE VOLUNTARY FURLOUGH FOR ANY OF THE FOLLOWING PURPOSES: SICK LEAVE, AS A
LEAVE WITHOUT PAY DUE TO DISABILITY, OR TO SEEK ALTERNATIVE EMPLOYMENT. I UNDERSTAND THAT IF I USE
VOLUNTARY FURLOUGH OR FURLOUGH EXTENSION LEAVE FOR A PURPOSE COVERED BY THE FEDERAL FAMILY
MEDICAL LEAVE ACT (FMLA) OR THE STATE FAMILY LEAVE ACT (FLA) WHICH DEEMS ME ELIGIBLE FOR COVERAGE
UNDER FMLA OR FLA, THE VOLUNTARY FURLOUGH OR EXTENSION SHALL BE RECORDED AS FMLA LEAVE, FLA LEAVE
OR BOTH.
NOTE: FURLOUGH EXTENSION LEAVES (MORE THAN 30 AND UP TO 60 ADDITIONAL DAYS IN A CALENDAR YEAR) MUST
BE TAKEN IN BLOCKS OF 10 DAYS, WHICH NEED NOT BE CONSECUTIVE, AND MAY ONLY BE USED FOR EDUCATION OR
FAMILY CARE NEEDS.
Yes
No
WHILE ON FURLOUGH EXTENSION LEAVE I WISH TO DISCONTINUE ALL OR PART OF MY HEALTH
BENEFITS PACKAGE.
SIGNATURE________________________________________DATE_____________________________________
PART E
AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION PURSUANT TO
THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT 45 C.F.R. 164.508
I,_________________________________DO HEREBY CONSENT AND AUTHORIZE_________________________________
(i.e. Name of Treating Doctor)
LOCATED AT __________________________________________TO RELEASE MY PROTECTED HEALTH INFORMATION
TO________________________________ REPRESENTING THE STATE OF NJ, DEPARTMENT OF CORRECTIONS.
(Human Resources Representative)
DISCLOSURE INCLUDES INFORMATION FROM MY CLINICAL RECORDS PERTAINING TO THE REASONS FOR THIS LEAVE
REQUEST, INCLUDING A TREATMENT SUMMARY. I UNDERSTAND THAT THE PURPOSE OF THIS DISCLOSURE IS IN
ACCORDANCE WITH MY REQUEST FOR A LEAVE OF ABSENCE AND TO DETERMINE WHETHER I AM CAPABLE OF
PERFORMING MY EMPLOYMENT DUTIES. I ALSO UNDERSTAND THAT THIS CONSENT IS REVOCABLE AT ANY TIME
UPON WRITTEN REQUEST AND THAT IT WILL REMAIN IN FORCE FOR A PERIOD OF 180 DAYS FROM THE DATE SIGNED,
UNLESS I SPECIFY OTHERWISE, IN ORDER TO EFFECTUATE THE PURPOSE FOR WHICH IT IS GIVEN. I UNDERSTAND
THAT THERE MAY NOT BE CONDITIONS ON TREATMENT, PAYMENT, ENROLLMENT OR ELIGIBILITY FOR BENEFITS
WHETHER OR NOT I SIGN THIS AUTHORIZATION. I UNDERSTAND THE POTENTIAL FOR INFORMATION DISCLOSED
PURSUANT TO THIS AUTHORIZATION TO BE SUBJECT TO REDISCLOSURE BY THE RECIPIENT AND NO LONGER
PROTECTED BY 45 C.F.R. 164.508
SIGNATURE______________________________________DATE_____________________________________
PART F
MANAGEMENT CERTIFICATION
FOR CENTRAL OFFICE USE
FOR INSTITUTION USE
APPROVED
______________________________________
APPROVED
SUPERVISOR/DEPARTMENT HEAD DATE
DISAPPROVED
SUPERVISOR/DEPT HEAD
DATE
DISAPPROVED
APPROVED
DIRECTOR
DATE
DISAPPROVED
APPROVED
______________________________________
APPROVED
ASSISTANT COMMISSIONER/
DATE
DISAPPROVED
ADMINISTRATOR /SUPT
DATE
DISAPPROVED
CHIEF OF STAFF/
COMMISSIONER
Revised 10/04
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