Employee ID (eg. 00123456):

First Name:*

Last Name:*

Preferred Email:*

Preferred Phone:*

Preferred Method of Contact:*

NIU Department:

Supervisor's Name:

Reason For Leave (Please check one):*

Placement for Adoption of Foster Care

Birth and Care of Newborn Child

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

Estimated Begin Date of Leave:*

Estimated End Date of Leave:*

**Please note, if foreseeable, requests for Parental Leave of Absence 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:

Continuous Leave:

Human Resource Services will assume that employees that are applying for Parental Leave of Absence and qualify for FMLA will be requesting 12 weeks of continuous leave of absence. Employees requesting a shorter continuous leave of absence or a leave of absence on an intermittent or reduced schedule basis should indicate in the space below their leave plan/schedule. Please note that Parental Leave of Absence, as provided in the Board of Trustee regulations, must be taken on a continuous basis. Human Resources Services will assume the paid Parental Leave of Absence benefits will be utilized immediately at the time of birth or placement unless indicated in the box below. Additionally, per the Federal FMLA regulations, employees are not entitled to take intermittent or reduced schedule leave for the birth and care of a newborn child or for the placement with the employee of a child for adoption unless the department is able to accommodate the request based on operational need.

Additional Leave:

For those employees that do not qualify for FMLA, additional time needed beyond the five weeks of Parental Leave of Absence will be considered for the medical necessity of the employee only and will be handled as a request for additional medical leave for the employee’s own serious health condition. Employees that may not qualify for FMLA, but would like to request additional leave of absence should indicate their leave plan/schedule request in the space below.

Paid Leave Benefit Designation:*

Following the five weeks of paid time from the University, employees are able to continue to be paid while on leave of absence by utilizing their accrued benefits. Please rank (by indicating 1, 2, 3) the order in which you wish to utilize your available paid leave benefits for the remainder of your leave of absence (subject to availability and applicable University policies).

Employees wishing to preserve any portion of their accrued sick, vacation (if applicable), and/or compensatory time (if applicable) should specify those limitations in the space below:

Disclosure: