1
This form provided by the Department of Administrative Services
State of Connecticut Human Resources
Employee Request
For Family and Medical Leave Entitlements
For information about specific leave entitlements, contact your Human Resources Office
(To be completed by Employee)
Form #: FMLA-HR1
Revision Date: 3/2018
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 FO
R LEAVE: (
Check reason)
For information about specific leave entitlements, contact your Human Resources Office
Personal Medical Leave
(for your
own serious health condition):
___ My own illness or injury
___ Dis
ability 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
__ Pa
rent
__ Pa
rent-in-law (State FMLA only)
__ Chil
d (under age 18 or age 18+ and incapable of self-care due to a
disability)
BondingLeave:
___ Birth of child
___ Ado
ption of child
___ P
lacement of foster child
(Federal and state 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
___ Mili
tary 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 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 da
y.
Intermittent Leave: Leave taken in separate blocks of time due to a single qualifying reason.
N
OTE:
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 Office 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 Office
.
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
s
tatus
.
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
c
hild and for caregiver leave. Your Human Resources Office will notify you if you meet the criteria for us
e
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 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
PERSONAL MEDICAL LEAVE
injury
Not Applicable
Not Applicable
to my pregnancy &
Not Applicable
Not Applicable
Organ donor (other
than the paid leave
entitlement of 15 days)
Not Applicable
Not Applicable
donor (other than the
paid leave entitlement
of 7 days)
Not Applicable
Not Applicable
CAREGIVER LEAVE
providing care to your wife
during the disability period
associated pregnancy and
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not Applicable
BONDING LEAVE
Not Applicable
Not Applicable
child
Not Applicable
Not Applicable
4
This form provided by the Department of Administrative Services
USE OF
ACCRUALS
Sick Leave
Accruals
Vacation
Accruals
Personal
Leave
Comp Time 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
Military Caregiver -
Covered Servicemember
Not
Applicable
Military Caregiver -
Covered Veteran
Not
Applicable
Qualifying Exigency
leave
Not Applicable
Not
Applicable
____________________________________________________ _______________
(Employee Signature) (Date)
Return the completed form(s) to your agency Human Resources Office.
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