Family Leave / Medical Leave / Child Care Leave/ Sick Leave/ Sabbatical/
Unpaid Leave
Leave Information	
Employee Name:				
Address:				
		
Position:		Location:		
Anticipated leave Date	                                              Anticipated Return Date:	

Type of Leave Requested: (mark all that apply)

**    N.J. Family or Federal Medical Leave Act       _______     Number of Weeks requesting (up to 12 weeks)

** Types of  Leaves  POLICY # 3431.1

                                                                         Birth or Placement of Child
                                                          Serious health condition of Family Member
                                                                         Serious health condition for Self

        Maternity    If paid maternity disability, number of weeks requesting ____________(up to 8 weeks) 

       Child Care                                                Adoption / Foster Care                               Dependent Care   

       Medical/sick Leave                                  Sabbatical                                                   Unpaid Leave
	
Reason for Leave:   Please attach reason/Medical Documentation to support your request (please attach)	
(   )  I have received a leave before                                    Dates of Previous Leave:
(   )  I have not received a leave before	
Completed by Human Resources Department	
		Paid Disability	Begin Date:                                            End Date:		
		         Personal Day Bank 	Begin Date:                                            End Date:		
		Paid Sick Days	Begin Date:                                            End Date:		
		Family Leave	Begin Date:                                            End Date:		
		Sabbatical Leave	Begin Date:                                            End Date:		
		Unpaid Leave	Begin Date:                                            End Date:		
Return Date:
(as per contract)			
If any clarification is needed concerning completion of this form or eligibility, please contact Human Resources at Ext. #6604.

Employee Signature			Date	
Principal  / Supervisor Signature		Date	

CC:  Payroll                                                                                 Board Approval Date ________________
Revised 04/19/12