Fillable Form 1: Designation Notice State of Connecticut Human

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Form 1: Designation Notice State of Connecticut Human

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1
This form provided by the Department of Administrative Services
State of Connecticut Human Resources
Designation Notice
Agency Response to Employee Request for Family Medical Leave Entitlements
(To
be completed by the Human Resources Office)
Form # FMLA-HR2b
Revision Date: 3/2018
TO: _________________________________________ _________________________________
(Employee Name) (Agency)
FROM: ______________________________________ _________________________________
(
Agency Human Resources Representative) (Telephone Number)
DATE: _______________________________________
REASON FOR LEAVE:
Personal Medical Leave (for your own
serious health condition):
___ My own illness or injury
___ Disability period related to my
pregnancy and childbirth
___ Organ donor
___ Bone marrow donor
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 (State FMLA 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 or state FMLA only)
Military Family Leave:
___ Qualifying Exigency arising out of the covered active duty of your
spouse, parent, or son or daughter
___ Military Caregiver leave for your spouse, parent, son, daughter or next
of kin who is a covered servicemember
___ Military Caregiver leave for your spouse, parent, son, daughter or next
of kin who is a covered veteran (Federal FMLA only)
We have reviewed yo
ur request for leave and any supporting documentation that you have provided. We received your most recent
information on (date)______________________________________and determined:
___ You are approved to take leave pursuant to one or more of the following leave entitlements:
____ Federal FMLA
____ State FMLA under C.G.S. 31-55kk
____ Pregnancy Disability Leave under C.G.S. 46a-60(b)(7)
____ SEBAC Supplemental Leave
____ Bone Marrow or Organ Donor Leave under C.G.S. 5-248k
See pages 2 , 3, & 5 - 7 for critical information about your leave entitlements, responsibilities and accrual usage.
You may be required to provide certification of your fitness-for-duty at the end of your leave. See page 3 for details.
___ Additional i
nformation is needed in order to determine whether your leave request can be approved.
See page 4 for an explanation of the additional information that will be needed.
___ You are not approved to take leave pursuant to one or more of the following leave entitlements:
____ Federal FMLA
____ State FMLA under C.G.S. 31-51kk
____ Pregnancy Disability Leave under C.G.S. 46a-60(b)(7)
____ SEBAC Supplemental Leave
____ Bone Marrow or Organ Donor Leave under C.G.S. 5-248k
See page 5 for an explanation of the reasons for the denials.
2
This form provided by the Department of Administrative Services
PART A: APPROVED LEAVES
You are approved to take leave under one or more of the following leave entitlements:
____ Leave under federal FMLA has been approved and all leave taken for this reason will be
designated as federal FMLA leave.
• Your annual federal leave entitlement will begin/began on (date) _________________________________.
• Your federal FMLA leave will run concurrently with a worker’s compensation leave. _____ Yes _____ No
• Your spouse ____ works/_____does not work for the State of Connecticut.
o He/she _____will/_____will not be taking leave for the same purpose.
• You are required to use your paid sick leave accruals if the absence is for your own serious illness.
• _____ You have requested to use paid leave accruals during your leave. Any paid leave taken for this reason will
count against your federal FMLA leave entitlement. (See pages 6 and 7)
•
You are required
to notify us as soon as practicable if the dates of scheduled leave change or are extended,
or were initially unknown. Based on the information you have provided to date, we are providing the following
information about the amount of time that will be counted against your federal FMLA leave entitlement:
_____ Pr
ovided there is no deviation from your anticipated leave schedule, the following number of
hours, days, or weeks will be counted against your leave entitlement:
_________________________________________________________________________________
____
_ Because the leave you will need will be unscheduled, it is not possible to provide the hours,
days, or weeks that will be counted against your federal FMLA entitlement at this time. You have the
right to request this information once in a 30-day period (if leave was taken in the 30-day period).
See F
orm FMLA-HR2c for more information about coding your time.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
____ Leave under C.G.S. 31-51kk has been approved and all leave taken for this reason will be
designated as “state FMLA leave.”
• Your annual state leave entitlement will begin/began on (date) _________________________________.
• Your state FMLA leave will run concurrently with a worker’s compensation leave. _____ Yes _____ No
• Your spouse ____ works/_____does not work for the State of Connecticut.
o He/she _____will/_____will not be taking leave for the same purpose.
• You are required to use your paid sick leave accruals if the absence is for your own serious illness.
• _____ You have requested to use paid leave accruals during your leave. Any paid leave taken for this reason will
count against your federal FMLA leave entitlement. (See pages 6 and 7)
•
You are
required to notify us as soon as practicable if the dates of scheduled leave change or are extended,
or were initially unknown. Based on the information you have provided to date, we are providing the following
information about the amount of time that will be counted against your federal FMLA leave entitlement:
_____ Pro
vided there is no deviation from your anticipated leave schedule, the following number of
hours, days, or weeks will be counted against your state FMLA leave entitlement:
_________________________________________________________________________________
_____ Bec
ause the leave you will need will be unscheduled, it is not possible to provide the hours,
days, or weeks that will be counted against your state FMLA entitlement at this time. You have the
right to request this information once in a 30-day period (if leave was taken in the 30-day period).
See F
orm FMLA-HR2c for more information about coding your time.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
___ Leave under C.G.S. 46a-60(b)(7) leave has been approved and all leave taken for this reason
will be designated as “pregnancy disability leave.”
• Your pregnancy disability leave entitlement will begin/began on (date) _________________________________.
3
This form provided by the Department of Administrative Services
• You are required to use your paid sick leave accruals during your pregnancy disability leave.
• _____ You have requested to use paid leave accruals during your leave. Any paid leave taken for this reason will
count against your pregnancy disability leave entitlement. (See pages 6 and 7)
•
You are required to notify us as soon as practicable if the dates of scheduled leave change or are extended,
or were initially unknown. Based on the information you have provided to date, we are providing the following
information about the amount of time that will be counted against your pregnancy disability leave entitlement:
_____ Provi
ded there is no deviation from your anticipated leave schedule, the following number of
hours, days, or weeks will be counted against your leave entitlement:
_________________________________________________________________________________
See Form FML
A-HR2c for more information about coding your time.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
____ Leave under the 2017 SEBAC Agreement has been approved and all leave taken for this reason
will be designated as “SEBAC Supplemental leave.”
• Your SEBAC Supplemental leave will begin/began _________________________________.
• _____ You have requested to use paid leave accruals during your leave. Any paid leave taken for this reason will
count against your SEBAC Supplemental leave entitlement. (See pages 6 and 7)
•
You are required to notify us as soon as practicable if the dates of scheduled leave change or are extended,
or were initially unknown. Based on the information you have provided to date, we are providing the following
information about the amount of time that will be counted against your SEBAC Supplemental leave entitlement:
_____ Provi
ded there is no deviation from your anticipated leave schedule, the following number of
hours, days, or weeks will be counted against your leave entitlement:
_________________________________________________________________________________
_____ Because the leave you will need will be unscheduled, it is not possible to provide the hours,
days, or weeks that will be counted against your SEBAC Supplemental entitlement at this time. You
have the right to request this information once in a 30-day period (if leave was taken in the 30-day
period).
See Form FM
LA-HR2c for more information about coding your time.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
____ Bone Marrow or Organ Donor leave under C.G.S. 5-248k has been approved.
•
Your bone marrow or organ donor leave entitlement will begin/began on (date) ________________________
and will end on ____________.
• You m
ust notify us as soon as practicable if the dates of scheduled leave change or are extended, or were initially
unknown.
See Form FMLA-HR2c for more information about coding your time.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
_____ Fitness-for-Duty: You will be required to return page 4 of the Medical Certificate (Form P33a)
certifying your fitness-for-duty prior to being restored to employment. If such certification is not timely received, your
return to work may be delayed until certification is provided.
A list of the essential functions of your position ____ is ____ is not attached.
If attached, the fitness-for-duty certification must address your ability to perform these functions.
Note: Failure to return to work at the end of your leave period may be treated as a resignation unless an
extension has been requested, agreed upon and approved in writing by the agency.
4
This form provided by the Department of Administrative Services
PART B: ADDITIONAL INFORMATION REQUIRED
Additional information is needed to determine if your leave request can be approved.
______ Incomplete/Insufficient Certification:
• The certification you have provided is incomplete or insufficient to determine whether your leave request can be
a
pproved.
• You must provide the following information no later than __________________
(provide at least 7 calendar days), unless it is
no
t practicable under the particular
circumstances despite your diligent good faith efforts, or your leave may be denied.
Specific information needed to make the certificate complete and sufficient:
____
_________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_______ Second/Third Opinion:
We are exercising our right to have you obtain a second or third opinion medical certification at our expense,
and we will provide further details at a later date.
5
This form provided by the Department of Administrative Services
PART C: LEAVE REQUESTS NOT APPROVED
_____ Federal FMLA leave is denied because:
____ The federal FMLA does not apply to your leave.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
____ You have exhausted your federal FMLA leave entitlement in the applicable 12-month period.
______
State family/medical leave (C.G.S. 31-51kk) is denied because:
____ The state family/medical leave does not apply to your leave request.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
____ You have exhausted your state family/medical leave entitlement in the applicable two-year period.
____ Leave under C.G.S. 46a-60(b)(7) is denied because this statute does not apply to your leave
request.
____ SEBAC Supplemental Leave is denied because:
____ SEBAC Supplemental leave does not apply to your leave request.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
____ You have exhausted your SEBAC Supplemental entitlement in the applicable two-year period.
____ Bone Marrow/Organ Donor Leave is denied because C.G.S. 5-248k does not apply to your
leave request.
PART D: USE OF ACCRUALS
• The choice to use your accruals must be made before you begin your leave.
o If you want change your accrual designation, you must contact your Human Resources Office.
o Accrual changes will be applied prospectively.
• If the reason for leave is for your own serious illness:
o Sick leave accruals must be used.
o Sick leave accruals must be exhausted before other 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.
6
This form provided by the Department of Administrative Services
Based on the information you provided to date, your accruals will be used as follows:
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)
Days/Hours
Days/Hours
Days/Hours
Days/Hours
Days/Hours
PERSONAL MEDICAL LEAVE
My own illness or
injury
If available,
must be used
Not Applicable
Not Applicable
Disability period related
to my pregnancy &
childbirth
If available,
must be used
Not Applicable
Not Applicable
Organ donor (other
than the paid leave
entitlement of 15 days)
If available,
must be used
Not Applicable
Not Applicable
Bone marrow
donation (other than
the paid leave
entitlement of 7 days)
If available,
must be used
Not Applicable
Not Applicable
CAREGIVER LEAVE
Spouse
(including
providing care to your wife
during the disability period
associated pregnancy and
childbirth)
Not Applicable
Parent
Not Applicable
Parent-in-law
Not Applicable
Not Applicable
Child
Not Applicable
BONDING LEAVE
Birth of child
Not Applicable
Adoption of child
Not Applicable
Placement of foster
child
Not Applicable
Not Applicable
7
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)
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
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Form 1: Designation Notice State of Connecticut Human

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Completed 25 July 2020

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