Employee ID (eg. 00123456):

 
Search Employee ID

First Name:*

   

Last Name:*

   

Preferred Email:*

   

Preferred Phone:*

   

Preferred Method of Contact:*

 Phone
 Email  

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.
 

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).  

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
 Email.
 Mailed to me at the address I specify below.  

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.

 Submitted by Employee.
 Submitted by someone other than Employee.

Fields marked with * are required.