Fillable FMLA Employee RequestHR1 (Central Connecticut State University)

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FMLA Employee RequestHR1 (Central Connecticut State University)

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The FMLA Employee RequestHR1 (Central Connecticut State University) form is 4 pages long and contains:

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  • 21 check-boxes
  • 100 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Central Connecticut State University

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1
This form provided by the Department of Administrative Services
State of Connecticut Human Resources
Employee Request
For Medical Leave, Family Leave or Military Family Leave
For information about specific leave entitlements, contact your Human Resources Department
(To be completed by Employee)
Form #: FMLA-HR1
Revision Date: 11/2017
Employee Name _____________________________ Employee No. _____________________________
Official Job Title ____________________________ Agency ___________________________________
Supervisor _________________________________ Supervisor Phone No. ______________________
Work Location ______________________________ Shift ____________Hours ____________________
Home Address _________________________________________________________________________
City________________________________________ State ________ Zip Code ____________________
Employee’s Personal Phone No. ____________________________________
Employee’s Personal Email _______________________________________________________________
REASON FOR LEAVE: (
Check reason)
For information about specific leave entitlements, contact your Human Resources Department
Personal Medical Leave
(for your
own serious health condition):
___ My own illness or injury
___ Disability period related to my
pregnancy and childbirth
___ Organ donation
___ Bone marrow donation
Caregiver Leave
(care for family member in connection with her disability
period related to pregnancy and childbirth, or his or her organ or bone marrow
donation or other serious health condition):
__ Spouse
__ Parent
__ Parent-in-law (C.G.S. 31-51kk only)
__ Child (under age 18 or age 18+ and incapable of self-care due to a
disability)
Bonding Leave:
___ Birth of child
___ Adoption of child
___ Placement of foster child
(Federal FMLA only)
Military Family Leave
:
___ Qualifying Exigency arising out of the covered active duty of my
spouse, parent, or son or daughter
___ Military Caregiver leave for my spouse, parent, son, daughter or
next of kin who is a covered servicemember
___ Military Caregiver leave for my spouse, parent, son, daughter or
next of kin who is a covered veteran (Federal FMLA only)
Does your spouse work for the State? ______ (yes) or ______ (no)
If YES:
Spouse’s Name: __________________________Spouse’s Agency: ______________________________
Will he/she be taking leave for the same purpose? _______ (yes) ____ (no)
2
This form provided by the Department of Administrative Services
TYPE OF LEAVE REQUESTED: (Check all that apply)
Block Leave: A one-time continuous absence for a single qualifying reason (e.g., one month).
Reduced Schedule Leave: A leave schedule that changes the employee’s normal work schedule for a
period of time by reducing the employee’s usual number of working hours per workweek or hours per day.
Intermittent Leave: Leave taken in separate blocks of time due to a single qualifying reason.
NOTE:
Intermittent leave and reduced schedule leave are not available in all situations. Availability of these types of leave depends upon
the reason for leave and your eligibility for specific leave entitlements. Contact your Human Resources Department for more
information.
Duration of Leave: (from) _________________________________ (to) _______________________
(month/day/year) (month/day/year)
Please describe your leave request:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
REQUESTED USE OF ACCRUALS:
• The choice to use your accruals during your absence must be made before you begin your leave.
o If you want to change your accrual designation, you must contact your Human Resources
Department.
o Accrual changes will be applied prospectively.
• If the reason is for your own personal medical leave:
o Sick leave accruals must be used.
o Sick leave accruals must be exhausted before other earned accruals can be used.
• If you do not elect to use your accruals, the leave will be unpaid.
• If you choose not to use all of your accruals or if your accruals are exhausted before the leave ends,
the remainder of the leave will be unpaid.
• If you elect to use your accruals, that paid time must be spent down completely before you go into unpaid
status.
• You cannot intermingle unpaid time with paid time.
• Depending upon the reason for leave and your eligibility for specific leave entitlements, you may be allowed
to use sick leave accruals for leave associated with bonding with a newborn child or newly placed adoptive
child and for caregiver leave. Your Human Resources Department will notify you if you meet the criteria for
use of sick leave accruals for these reasons.
3
This form provided by the Department of Administrative Services
Fill In Chart: You must designate the number of days, or hours, or you may indicate “ALL available.”
USE OF
ACCRUALS
Sick Leave
Accruals
Vacation
Accruals
Personal
Leave
Comp Time
Accruals
Sick Family
Days (based
on bargaining
unit contract)
Parental
Days (based
on bargaining
unit contract)
REASON
Days/Hours
Days/Hours
Days/Hours
Days/Hours
Days/Hours
PERSONAL MEDICAL LEAVE
My own illness or
injury
Not Applicable
Disability period related
to my pregnancy &
childbirth
Not Applicable
Organ donation
(after
exhaustion of paid leave
entitlement of 15 days)
Not Applicable
Bone marrow
donation (after
exhaustion of paid leave
entitlement of 7 days)
Not Applicable
CAREGIVER LEAVE
Spouse (including
providing care to your wife
during the disability period
associated pregnancy and
childbirth)
Parent
Parent-in-law
Not Applicable
Child
BONDING LEAVE
Birth of child
Not Applicable
(unless child is
sick)
Adoption of child
Not Applicable
(unless child is
sick)
Placement of foster
child
Not Applicable
(unless child is
sick)
4
This form provided by the Department of Administrative Services
USE OF
ACCRUALS
Sick Leave
Accruals
Vacation
Accruals
Personal
Leave
Comp Time
Accruals
Sick Family
Days (based
on bargaining
unit contract)
Parental
Days (based
on
bargaining
unit contract)
REASON
Days/Hours
Days/Hours
Days/Hours
Days/Hours
Days/Hours
Days/Hours
MILITARY FAMILY LEAVE
MilitaryCaregiver -
Covered Servicemember
Not
Applicable
Military Caregiver -
Covered Veteran
Not
Applicable
Qualifying Exigency
leave
Not Applicable
Not
Applicable
____________________________________________________ _______________
(Employee Signature) (Date)
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FMLA Employee RequestHR1 (Central Connecticut State University)

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Completed 21 July 2020

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