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Parental Leave of Absence Request Form

Important Information Regarding your Leave of Absence Request

Before applying for Parental Leave of Absence, employees are required to review the the information in the Parental Leave of Absence Fact Sheet.


Acknowledgement Signature:*

By signing below I am certifying that I have read the Parental Leave of Absence Fact Sheet. If I have any questions regarding the information contained in this document it is my responsibility to contact Human Resource Services.
 Sign using your S-signature eg. /Victor E. Huskie/ (forward slash on each side of your name).

   

Employee Information

Employee ID (eg. 00123456):

 
Search Employee ID
 

First Name:*

   

Last Name:*

   

Preferred Email:*

   

Preferred Phone:*

   

Preferred Method of Contact:*


 

NIU Department:


Supervisor's Name:


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Leave Requested

Reason For Leave (Please check one):*



 

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.

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).

Sick Leave:  
Vacation:  
Compensentory Time:  

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:

Employees may request in writing to change their benefit designation preference after they have been initially submitted. The request should be sent to FMLA@niu.edu. Any changes will not be retroactive, but will take effect durning the next payroll period.
Fields marked with * are required.

Disclosure:

By using this website you agree that your Name and/or ID fully, accurately and uniquely identifies you in our database. You furthermore agree that your submission of this form, via the "I Accept" button, shall constitute the execution of this document in exactly the same manner as if you had signed, by hand, a paper version of this agreement.
 
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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 Parental leave or email FMLA@niu.edu.