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New Jersey Family Member Medical Certification Form

Author: Katherine Hinde, Littler

When to Use

A covered New Jersey employer may use this form if the employer requires an employee to provide a medical certification supporting a request to take leave under the federal Family and Medical Leave Act (FMLA) and/or the New Jersey Family Leave Act (NJFLA) to care for a family member with a serious health condition.

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