New Jersey Family and Medical Leave of Absence Request Form

Author: Katherine Hinde, Littler

When to Use

A covered employer in New Jersey can use this form to receive employee requests for a family and medical leave of absence covered by the federal Family and Medical Leave Act (FMLA) and/or New Jersey Family Leave Act (NJFLA).

Employer coverage under these laws are as follows:

• The FMLA covers employers that employ 50 or more employees in 20 or more workweeks in the current or preceding calendar year that are engaged in commerce or in any industry or activity affecting commerce.
• The NJFLA covers employers that employ 30 or more employees for each working day during each of 20 or more workweeks in the current or preceding calendar year. All employees do not have to be in New Jersey - even employees that work outside of New Jersey are included in determining whether an employer is a covered employer. In some situations, employees of a subsidiary or related entity also must be considered.

Customizable Form