Employee Name* First Last Lawson ID*Job Title*Address*Home PhoneBest Contact Number*Personal Email Address* I am requesting a Leave of Absence for the reason listed below. I understand that my eligibility under any of these leave types will be determined by the Leave Specialist and that the Leave Specialist will notify me of my eligibility in writing. We can only accept your request if your Leave of Absence is set to begin within 45 days of the current date. I am requesting:*Continuous -Defined as an absence lasting three or more business days.Intermittent - Defined as an absence taken in separate blocks of time.Reasonable AccommodationExpected First Day Out* Date Format: MM slash DD slash YYYY Estimated Return to Work Date* Date Format: MM slash DD slash YYYY Leave Type*Medical (FMLA) - For my own serious health condition.Medical (FMLA) - PregnancyFamily (NJFLA) - To care for a family member with a serious health condition. Please provide the family member's relationship to you.Family (NJFLA) - To care for a newborn child or for the placement of a child from adoption or from foster care. The date of placement/birth/adoption is requiredOther - Military (we will need a copy of your leave orders)Other - Personal (submit your request for personal leave in writing to your manager)I am requesting a Reasonable Accommodation in order to perform the essential functions of my job. Please provide additional information regarding your request: The birth of a child is a qualified change in status event and allows you to make changes to your benefit elections. If you wish to make any changes to your benefits a Change in Status Events Form and proper documentation must be submitted to the Benefits Department within 31 days of the child’s date of birth, otherwise you must wait until the next Annual Open Enrollment period. If you have any questions, please contact the Benefits Department at 856-342-2403 or via email at HRBenefits@cooperhealth.edu. Expected Date of Delivery* Date Format: MM slash DD slash YYYY Family Member's Relation to You*SpouseParentChildChild's DOB* Date Format: MM slash DD slash YYYY Additional information you want to provide regarding your leave request:Please indicate how you wish to receive information about your leave:*Your leave request will be processed within 24-48 hours. If you elect to receive information via email, the email will be coming from email@example.com. If the message does not appear in your inbox, please check your junk mail and/or spam folders.Personal EmailU.S. Mail(Legacy)Personal Email Address CAPTCHAEmailThis field is for validation purposes and should be left unchanged.