Employee ID (eg. 00123456):

 
Search Employee ID

First Name:*

  First name is a required field.

Last Name:*

  Last name is a required field.

Preferred Email:*

  Email is a required field.

Preferred Phone:*

  Phone is a required field.

Preferred Method of Contact:*

Phone

Email

Please select a preferred method of contact.

Supervisor's Name:

Search NIU Directory

Reason For Leave (Please check one):*

Birth & Care of Newborn Child.

Placement for Adoption of Foster Care.

Employees own Serious Health Condition.

Care for family member with Serious Health Condition.

Care for Covered Service Member with a Serious Illness or Injury.

Qualifying exigency arising from a family member on covered active duty.

Please select a reason for leave.

Family Member Information

(Spouse, Civil Union Partner, Domestic Partner, Child or Parent Information)

Placement for Adoption of Foster Care

Birth and Care of Newborn Child

Service Member Information

(Spouse, Civil Unoin Partner, Domestic Partner, Child Parent, or Next of Kin)

Type of Leave Requested (Check all that may apply):*

Continuous Leave (Single continuous period of time).

Intermittent Leave (Multiple, sporadic periods of time).

Reduced Schedule (Set hours per day).

Please select at least one item.

Estimated Begin Date of Leave:*

 
Begin date of leave is a required field.

Estimated End Date of Leave:*

 
End date of leave is a required field.

Last Day Worked:*

 
Last day worked is a required field.

**Please note, if foreseeable, requests for medical leave should be made at least thirty (30) days in advance of the leave or as soon as practicable. If the need for leave is not foreseeable, requests should be made within two business days of learning of the need for leave. If the Estimated Begin Date for Leave listed above is not more than thirty (30) days in the future, please indicate on the lines below the reason for the delay in notifcation:

Please indicate the reason for delay.

FMLA Packet*

Please Indicate how you would like to recieve your FMLA Packet

Email.

Mailed to me at the address I specify below.

FMLA Packet is a required field.

Please provide the mailing address where you would like the FMLA Packet to be sent:

Please provide the mailing address information.

Please indicate if this form is being submitted by someone other than the employee requesting FMLA Leave.

Submitted by Employee.

Submitted by someone other than Employee.

Fields marked with * are required.