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New Jersey Family and Medical Leave Notice of Eligibility and Rights and Responsibilities Form

Author: Katherine Hinde, Littler

When to Use

This form may be used to inform employees of their eligibility for, and rights and responsibilities under, the Family and Medical Leave Act (FMLA) and the New Jersey Family Leave Act (NJFLA). Under the FMLA, the employer must notify the employee whether they are eligible for FMLA leave within five business days of the employee's request. Each time an employer must provide the eligibility notice to an employee, it must also provide an FMLA rights and responsibilities notice.

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