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FMLA Request Form

Important information regarding your request

To receive a Family Medical Leave Act (FMLA) information packet and full application, please complete the following form. Human Resource Services will notify you within five business days of the receipt of this form of your eligibility for FMLA. At that time, an information packet and the necessary forms will be provided.

Upon receipt of this form, Human Resource Services will notify your supervisor of your request for leave, including your general reason for leave, if the leave is for yourself or a family member, your type of leave (continuous or intermittent), and the estimated dates of your leave as you indicate below. Specific medical conditions/information will not be shared.

Employees must follow their departmental call-in procedures for any absences until their requests for leave has been received, reviewed, and approved. A notification will be sent to the employee and their supervisor upon approval of the leave request.


Employee Information


Employee ID

  Search Employee ID

First Name*

 

Last Name*

 

Preferred Email*

 

Preferred Phone*

 

 

Preferred Method of Contact (Please select one):*


 

Supervisor's Name:

  Search NIU Directory

 

Leave Requested



 

Reason For Leave (Please check one):*






 
 

Family Member Information

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


First Name of Family Member:

 

Last Name of Family Member:

 

Relationship:

 
 

Placement for Adoption of Foster Care


Estimated Date of Placement:*

 
 

Birth and Care of Newborn Child


Estimated Due Date:*

 

Please indicate if your spouse is an NIU employee and will be taking leave for the same reason. If so, please indicate spouse’s name.


 

Service Member Information

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


First Name of Service Member:*

 

Last Name of Service Member:*

 

Relationship:*

 
 

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



 

 

Estimated Begin Date of Leave:*

 

Estimated End Date of Leave:*

 

Last Day Worked:*

 

 

**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:


 

 

FMLA Packet*

Please Indicate how you would like to recieve your FMLA Packet



 

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


 

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


Leave Requested by (Include first and last name):*


 

Relationship:

 

 

 
Fields marked with * are required.
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Need more information?

Please call the HRS Service Center at 815-753-6000 and ask to be connected to one of our HR associates regarding the application process for a FMLA leave or email FMLA@niu.edu.