Leave of Absence Information and Forms

Capital Health System provides eligible employees who need to be out of work for more than 7 calendar days a leave of absence in accordance with the provisions of the Federal Family Medical Leave Act (FMLA), the Temporary Disability Law of the State of New Jersey and/or the New Jersey Family Leave Act (NJFLA). If not eligible for FMLA , NJ Short-Term Disability or NJFLA, CHS also provides a Personal Leave.

The type of leaves available are described below:

Federal Family Medical Leave Act (FMLA)

Reasons for a leave

Serious health condition of your own

Serious health condition of the employee's spouse, child, or parent

Birth of a child, or the placement of a child with you for adoption or foster care

To care for a covered service member who is recovering from a serious illness or injury sustained in the line-of-duty on active duty.

New Jersey Family Leave Act (NJFLA)

Reasons for a leave

To care for a spouse, child, parent, or parent-in-law

Both FMLA and NJFLA provide a job guarantee and health insurance continuation for up to 12 weeks. Neither FMLA nor NJFLA is a paid leave but the employee may use PTO during his/her leave of absence and/or file for NJ State disability if applicable.

New Jersey Short-Term Disability

If you have a non-work related illness or injury and it requires you to be absent more than 7 consecutive calendar days, you can apply for short-term disability leave benefits. CHS short-term disability benefits are in accordance with the Temporary Disability Law of the State of New Jersey. It provides income protection in the event of a short-term disability up to a maximum of 26 weeks, based upon your meeting specific eligibility requirements.

When you are on short-term disability, the time is counted simultaneously as a family and medical leave under the Federal Family Medical Leave Act (FMLA), provided you have met the eligibility requirements.

Personal and/or Personal/Medical Leave

Reasons for leave

Not eligible for FMLA/NJFLA

FMLA entitlement has been exhausted in the prior 12 month period

Job Related Education

Military

Jury duty

Other circumstances due to serious personal reasons

If you are on personal leave for reasons other than your own illness, you must use all of your accrued PTO time before taking time off without pay.

While on a personal or personal/medical leave you do not have a job guarantee. Upon return from leave, if your position has been filled, your employment will end with CHS.

Health, dental and life insurance will terminate the last day of the month that the personal or personal/medical leave began unless you resume your prior status within 30 days of the start of your personal or personal/medical leave. Insurance can be continued through COBRA. You will be responsible for the full cost of coverage.

You are eligible for FMLA (Federal Family Medial Leave Act)/NJFLA (NJ Family Leave Act) provided you have:

1. Been employed by CHS for at least one year from your hire date; and
2. Worked at least 1,000 hours in the twelve (12) months prior to the date in which the leave is to begin (this equates to working at least 20 hours a week).
3. Have not been on a leave in the last 12 months and already exhausted your12 weeks of time allowable away from the job.

If you do not fit these criteria you may apply for a personal or personal/medical leave. (To verify your eligibility contact Human Resources at 609-815-7418 or 609-394-4076.)

1. Notify your supervisor that you are unable to work and are applying for leave and/or NJ State (short-term) disability.
2. Fill-out the proper forms and submit to Human Resources, Mercer campus within 15 days prior to the start of your absence.

In order to determine your eligibility and receive approval for your leave, you MUST complete and submit the following forms to Human Resources, Mercer Campus 15 days prior to taking a leave of absence:

Forms for an FMLA (Federal Family Medical Leave) Leave:

Request for Leave of Absence Form
Certification of Healthcare Provider Form
Supplemental Pay Request Form
New Jersey State Temporary Disability Form (complete only if applying for NJ State Benefits)
Federal Income Tax Withholding Form (optional)
Return to Work Certification Form
CHS Family/Medical Leave policy (5.5)

Forms for NJFLA (New Jersey Family Leave Act) Leave:

Request for Leave of Absence Form
Certification of Healthcare Provider Form
Supplemental Pay Request Form
CHS Family/Medical Leave policy (5.5)

Forms for Personal/ Medical Leave:

Request for Leave of Absence Form
New Jersey State Temporary Disability Form (only if applying for NJ State Benefits)
Federal Income Tax Withholding Form (optional)
Supplemental Pay Request Form
Return to Work Certification Form
CHS Personal Leave policy (5.6)

Forms for Personal Leave:

Request for Leave of Absence Form
Supplemental Pay Request Form

The Certification of Health Care Provider Form certifies that you are under the care of a physician. It is to be completed by your physician when you are applying for FMLA (Federal Family Medical Leave Act) for your own illness or by your family member's physician if the leave is to care for an immediate family member.

PDF - (Medical Certification Form)

Income

If on a leave due to your own illness or injury, you may be eligible to receive income from the New Jersey State short-term disability benefit. In addition, eligible full- and part-time employees who receive income from these sources may have this income supplemented with the CHS Supplemental Sick Pay Plan (Policy 4.14)

If you receive NJ State short-term disability benefits, you may receive 66 2/3% of your pay. If you are eligible for the maximum NJ State short-term disability benefit rate you may also be eligible for CHS's supplemental pay to meet the 66 2/3%.

You may elect to further supplement this income using frozen sick or PTO time enabling you to reach 100% of your pay. At no time will supplementing NJ State short-term disability with frozen sick or PTO result in you receiving more that 100% of your budgeted weekly earnings. If you elect to use accrued time, you must complete a Supplemental Pay Request Form.

PDF - (Supplemental Pay Request Form)

You are responsible for paying your portion of medical and/or dental during your leave to ensure uninterrupted service.

Health Benefits

When approved for FMLA or NJFLA health benefits are continued for up to 12 weeks if you continue to pay your portion of the medical and/or dental contribution during your leave of absence. If you are on personal leave, you will have your coverage terminate the last day of the month that your personal leave begins unless you resume your prior status within 30 days of your leave. You will be notified under separate cover of your benefit continuation options under COBRA. You will be responsible for the full cost of this coverage.

When you are out on a leave for you own serious health condition, you will need to receive a "fit for duty" medical clearance from our Corporate Health Center.

You will need to:

1. Have your physician complete the CHS return to work certification form
2. Make an appointment with the Corporate Health Center at 609-695-7471
3. Bring the completed form with you to the Corporate Health Center
4. Contact your Manager to coordinate your return

PDF - (Return to Work Form)

If approved for an FMLA (Federal Family Medical Leave) or NJFLA (NJ Family Leave), you are guaranteed to return to the same or comparable position. If you are out past 12 weeks, allowable by FMLA/NJFLA, you are no longer eligible for a job guarantee.

When you are on NJ short-term disability, the time is counted simultaneously as a family and medical leave under the Federal Family and Medical Leave Act (FMLA), provided you have met the eligibility requirements.

Capital Health System Family/Medical Leave Policy 5.5

PDF - (CHS Family/Medical Leave Policy)

Should you have questions or need assistance in completing these forms, you can contact Human Resources at 609-815-7418 or 609-394-4076.