Family Leave (Nlfla) & Family and Medical Leave Act (Fmla) Application Form - Wall Township, New Jersey

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NEW JERSEY STATE FAMILY LEAVE (NLFLA) &
FAMILY AND MEDICAL LEAVE ACT (FMLA)
New Jersey Family Leave (NJFLA)
Eligibility Requirements: Have worked for covered employer at least 1000 hours in preceding 12 months and employed for at least 12 months.
Amount of Leave: 12 weeks during a 24 month period measured forward from the first date of any NJ State Family Leave granted within the
last 24 months.
Type of Leave: Birth or adoption; serious health condition of parent, parent of spouse, child or spouse (This type of leave can be used to care
for family not oneself)
Family & Medical Leave Act (FMLA)
Eligibility Requirements: Have worked for covered employer at least 1250 hours in preceding 12 months and employed for at least 12 months.
Amount of Leave: 12 weeks during a 12 month period measured forward from the first date of any FMLA granted within the last 12 months.
Type of Leave: Birth, adoption, or foster care; to care for parent, child, or spouse with serious health condition or employees’ own serious
health condition. (This type of leave can be used to care for family or oneself)
Health Benefits Coverage
Your health benefits will be maintained under the same conditions as if you continued to work. If you pay a health benefits premium
contribution through payroll deduction, you will be advised of any premium contribution that might be due in order to continue your coverage
during your leave period. If you do not remit these premium contributions as requested, the District may recover these payme nts from you
upon your return to work.
Reinstatement Rights
You are entitled to be restored to the same position you held before the leave started, or to an equivalent position with equivalent benefits, pay
and other terms and conditions of employment.
Medical Certification
Certification from an appropriate health care provider of your own serious health condition or the serious hea lth condition of your family
member must be presented to the Office of Human Resources. If the period of illness extends beyond the date originally provi ded, medical
certification will be required to confirm extension of illness. In addition, you will be required to present a fitness-for-duty certificate prior to
being restored to employment if your absence was due to your own serious health condition.
_____________________________________________________________________________________________________________Please be advised
that if the circumstances of your leave qualify for FMLA and NJFLA, the leave used will count against your entitlement under both laws.
I have read this notice and am applying for Family Leave under the terms and conditions as defined above:
Name: ___________________________________
Department: _________________________________
Start Date of Anticipated Leave: __________________
Expected Date of Return: ______________________
Reason of Leave: ______________________________________________________________________________________________
Employee’s signature: ____________________________________________________Date: ________________________________
Supervisor’s signature: ____________________________________________________Date: ________________________________
_____________________________________________________________________________________________ _________________
The Human Resources Office has reviewed your request for Family Leave and advise that you are eligible for the following:
__________FMLA
__________NJFLA
__________Both FMLA and NJFLA
__________Not eligible for Family Leave for the following reason(s):_________________________________________________
______________________________________________________________
Human Resources Representative: __________________________________________ Date: _______________________________
This application provides general information only and is not intended to encompass all aspects of leave set forth within the Wall
Township Board of Education Policy No. 4431.1 applicable to Family Medical Leave.
NEW JERSEY STATE FAMILY LEAVE (NLFLA) &
FAMILY AND MEDICAL LEAVE ACT (FMLA)
New Jersey Family Leave (NJFLA)
Eligibility Requirements: Have worked for covered employer at least 1000 hours in preceding 12 months and employed for at least 12 months.
Amount of Leave: 12 weeks during a 24 month period measured forward from the first date of any NJ State Family Leave granted within the
last 24 months.
Type of Leave: Birth or adoption; serious health condition of parent, parent of spouse, child or spouse (This type of leave can be used to care
for family not oneself)
Family & Medical Leave Act (FMLA)
Eligibility Requirements: Have worked for covered employer at least 1250 hours in preceding 12 months and employed for at least 12 months.
Amount of Leave: 12 weeks during a 12 month period measured forward from the first date of any FMLA granted within the last 12 months.
Type of Leave: Birth, adoption, or foster care; to care for parent, child, or spouse with serious health condition or employees’ own serious
health condition. (This type of leave can be used to care for family or oneself)
Health Benefits Coverage
Your health benefits will be maintained under the same conditions as if you continued to work. If you pay a health benefits premium
contribution through payroll deduction, you will be advised of any premium contribution that might be due in order to continue your coverage
during your leave period. If you do not remit these premium contributions as requested, the District may recover these payme nts from you
upon your return to work.
Reinstatement Rights
You are entitled to be restored to the same position you held before the leave started, or to an equivalent position with equivalent benefits, pay
and other terms and conditions of employment.
Medical Certification
Certification from an appropriate health care provider of your own serious health condition or the serious hea lth condition of your family
member must be presented to the Office of Human Resources. If the period of illness extends beyond the date originally provi ded, medical
certification will be required to confirm extension of illness. In addition, you will be required to present a fitness-for-duty certificate prior to
being restored to employment if your absence was due to your own serious health condition.
_____________________________________________________________________________________________________________Please be advised
that if the circumstances of your leave qualify for FMLA and NJFLA, the leave used will count against your entitlement under both laws.
I have read this notice and am applying for Family Leave under the terms and conditions as defined above:
Name: ___________________________________
Department: _________________________________
Start Date of Anticipated Leave: __________________
Expected Date of Return: ______________________
Reason of Leave: ______________________________________________________________________________________________
Employee’s signature: ____________________________________________________Date: ________________________________
Supervisor’s signature: ____________________________________________________Date: ________________________________
_____________________________________________________________________________________________ _________________
The Human Resources Office has reviewed your request for Family Leave and advise that you are eligible for the following:
__________FMLA
__________NJFLA
__________Both FMLA and NJFLA
__________Not eligible for Family Leave for the following reason(s):_________________________________________________
______________________________________________________________
Human Resources Representative: __________________________________________ Date: _______________________________
This application provides general information only and is not intended to encompass all aspects of leave set forth within the Wall
Township Board of Education Policy No. 4431.1 applicable to Family Medical Leave.

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