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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
(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
(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)
:
___ 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)