This form provided by the Department of Administrative Services
State of Connecticut Human Resources
Intent to Return to Work
Form #: FMLA - HR-3
Revision Date: 1/2009
_________________________________________________________________________________________________
(To be completed by the employee prior to taking leave under federal FMLA and/or C.G.S. 5-248a.
Family and medical leave from employment.)
Connecticut General Statute 5-248a(d) and Regulations of Connecticut State Agencies Sec. 5-248b-3 through Sec. 5-
248b-7 require that any permanent employee who requests a family or medical leave of absence under C.G.S. 5-248a
prior to the inception of such leave, to submit to the employee’s appointing authority a signed statement of the
employee’s intent to return to his/her position in State service upon termination of the leave.
Section 825.311 of the Code of Federal Regulations permits the employer to require an employee on FMLA leave to
report periodically on his/her status and intent to return to work. This form may be used for that purpose also.
I hereby confirm my intention to return to work at its conclusion. ______________________________________.
(Fill in “yes” or “no.”)
The projected end date of my leave is ____________________________________________________________.
_______________________________________________
(Employee Name – Print)
________________________________________________ ______________________________
(Employee Signature) (Date)
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signature
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