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This form provided by the Department of Administrative Services
Stat
e of Connecticut Human Resources
Notice of Eligibility and Rights and Responsibilities
regarding Employee Request for Family Medical Leave Entitlements
(To be completed by the Human Resources Office)
Form #: FMLA-HR2a
Revision Date: 3/2018
This form will:
Notify you if you meet the eligibility criteria for one or more of the Family Medical Leave Entitlements
created by federal and state statute, state policy and collective bargaining agreements;
Notify you of the information you need to provide to Human Resources to support your request for
leave;
Advise you of the rights and responsibilities you will have if you are approved to take leave.
This form does not constitute an approval of your leave request.
After Human Resources receives the information from you as specified below, you will receive a
designation notice, telling you if:
Your leave has been approved, and if so, whether it counts toward one or more of the Family Medical
Leave Entitlements created by federal and state statute, state policy and collective bargaining
agreements, and how any accrued paid leave will be used; or
Your leave has been denied; or
You need to provide additional information.
Thi
s form provides employees with the information regarding their eligibility for federal FMLA leave and their rights and
responsibilities for taking federal FMLA leave as required by 29 C.F.R. 825.300(b), (c).
PART A: NOTICE OF ELIGIBILITY
TO: _____________________________________________________ _________________________
(Employee Name) (Agency)
FROM: __________________________________________________ _________________________
(Agency Human Resources Representative) (Telephone Number)
DATE: ________________________________
On ________________, you notified us of your need to take family/medical leave or military family leave.
Requested Dates of Leave: From______________________________ To___________________________________
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This form provided by the Department of Administrative Services
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 and 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)
Federal FMLA:
To be eligible, an employee must have worked for the employer for at least 12 months, have worked at least 1,250 hours
in the 12 months preceding the leave, and worked at a site with at least 50 employees within 75 miles.
_________ You are eligible for federal FMLA Leave (See Part B and C)
_______
__ You are not eligible for federal FMLA leave because:
(
only one reason need be checked, although you may not be eligible for other reasons)
____ You have not met the federal FMLA 12-month length of service requirement. (As of the first date of
requested leave, you will have worked approximately __________months towards this requirement.)
__
___ You have not met the federal FMLA 1,250 hours-worked requirement. (As of the first date of
requested leave, you will have worked approximately __________hours towards this requirement.)
____ Y
ou do not work and/or report to a site with 50 or more employees within 75-miles.
If
you have any questions, contact ________________________________________ or view the FMLA poster located in
______________________________________________.
State Family/Medical Leave (C.G.S. 31-51kk):
_________ You are eligible for state FMLA Leave under C.G.S. 31-51kk. (See Parts B & C)
_______
__ You are not eligible for state FMLA leave under C.G.S. 31-51kk because:
(
only one reason need be checked, although you may not be eligible for other reasons)
____ You have not met the state FMLA 12-month length of service requirement. (As of the first date of
requested leave, you will have worked approximately __________months towards this requirement.
_____ You have not met the state FMLA 1,000 hours-worked requirement. (As of the first date of
requested leave, you will have worked approximately __________hours towards this requirement.
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This form provided by the Department of Administrative Services
Supplemental Leave under SEBAC 2017:
To qualify for supplemental leave, you must be a permanent” employee as defined in C.G.S. 5-196(19).
______
__ You are eligible for supplemental leave. (See Parts B & C)
_______
_ Are not eligible for supplemental leave because
_____
You are an employee in classified service who has not successfully completed your required initial working test period.
______ You are an employee in unclassified service who has not served in your position for at least six (6) months.
Pregnancy Disability Leave (C.G.S. 46a-60(b)(7)):
_______ Pursuant to C.G.S. 46a-60(b)(7) you are entitled to take a reasonable leave of absence for the disability resulting from
y
our pregnancy.
Bone Marrow or Organ Donor Leave (C.G.S. 5-248k):
_______ As a state employee you are eligible to take leave up to 15 days for organ donation and up to 7 days for bone marrow
donation.
PART B: DOCUMENTATION NEEDED TO ASSESS YOUR LEAVE REQUEST
As indicated above, you meet the eligibility requirements for one or more of the family/medical leave or military family leave
entitlements available to employees of the State of Connecticut. In order for us to determine whether the reason for your leave
qualifies under the family/medical leave or military family leave entitlements available to employees of the State of Connecticut, the
agency Human Resources Office needs additional information.
You
must return the following documentation to Human Resources by ___________________________ (date). (Check all that apply)
_____ Form P33a Employee - To substantiate the employee’s own “serious health condition including pregnancy.
_____ Form P33b Caregiver -To substantiate that the employee is needed to care for a spouse, child, parent, or parent-in-law with a
“serious health condition”.
______ Bonding with a newborn child - A written statement asserting that the requisite family relationship exists, or other documentation such
as a child’s birth certificate or a court document.
______ Adoption - A written statement asserting that the requisite family relationship exists, or other documentation such as child’s adoption
papers or a court document.
______ Placement of a foster child with youA written statement asserting that the requisite family relationship exists, or other
documentation, such as a letter from the state establishing placement date.
______ Form DOL-WH384Certification of Qualifying Exigency for Military Family Leave.
______ Form DOL-WH385 - Certification for Serious Injury or Illness of Current Servicemember for Military Caregiver Leave.
______ Form DOL-WH385-VCertification for Serious Injury or Illness of a Veteran for Military Caregiver Leave.
______ Documentation to establish the required relationship between you and your family member.
______ No additional certification documentation is requested.
If sufficient documentation is NOT provided in a timely manner, your leave may be denied.
You will also need to submit the following completed forms: (Check all that apply)
______ FMLA- HR1Employee Request for Leave of Absence
______ FMLA- HR3Intent to Return to Work
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This form provided by the Department of Administrative Services
PART C RIGHTS AND RESPONSIBILITIES FOR TAKING FAMILY/MEDICAL OR
MILITARY FAMILY LEAVE
If your leave does qualify as family/medical leave or military family leave, you will
have the following responsibilities
while on leave:
Benefits:
During your paid and/or unpaid family/medical leave, there will be no change in your existing benefits.
The State will continue to pay the same portion of your individual and dependents’ health coverage as it did prior to the
leave.
While on unpaid leave, you will be billed directly by __________________________________ for your portion of the cost.
Federal FMLA provides employees on FMLA leave a minimum 30-day grace period in which to make premium payments.
If payment is not made timely, federal law allows the state to cancel group health insurance, provided it notifies you in
writing at least15 days before the date that your health coverage will lapse,
Under federal law, the State has the option of paying your share of the premiums during federal FMLA leave, and recovering
these payments from you upon yo
ur return to work.
o (check one) The State ____will/ ____will not pay your share of health insurance premiums while you are on leave.
If you have state-sponsored group life insurance and are unpaid leave, you will be billed at the same rate you were paying
prior to the leave.
If you are having other deductions taken from your paycheck (e.g., disability insurance, BSL life insurance, credit union
loans, deferred compensation) you should contact the vendor directly to discuss payment options.
Sick Leave:
You will be required to use all of your available sick leave accruals during your family/medical leave absence if the absence is for
your own serious illness or injury. This means that you will use your sick leave accruals and the leave will also be considered
protected family medical leave and counted against your family medical leave entitlement.
Periodic Reports
While on leave, you will be required to furnish us with periodic reports of your status and intent to return to work every:
(Indicate interval of periodic reports, as appropriate for the particular leave situ
ation)
__________________________________________________________________________________________________
__
________________________________________________________________________________________________
__________________________________________________________________________________________________
If the circumstances of your leave change, and y
ou are able to return to work earlier than the date indicated on the this form, you will be required
to notify us at least two workdays prior to the date you intend to report for work.
Service Credit:
Unless otherwise specified in your labor contract, leaves of absence without pay are deducted from service credit for longevity
purposes.
You should consult your contract’s seniority article for information on whether the time spent on unpaid leave is creditable
toward general or layoff seniority.
You should also consult your pension plan regarding time spent on unpaid leave.
Key Employee:
Federal FMLA defines “key employee” as a salaried, FMLA-eligible employee who is among the highest paid 10 % of all the
employees working for the employer within 75 miles of the employee’s worksite.
Under federal FMLA, the employer may deny individuals designated as a “key employee” reinstatement to their positions
following their FMLA leave.
The State of Connecticut does not design
ate any employees as “key employees” under federal FMLA.
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This form provided by the Department of Administrative Services
If your leave does qualify as federal or state family/medical leave or military family leave,
you will have the following rights while on leave:
You have a right under the federal FMLA for up to 12 workweeks of leave (unpaid or paid using accruals) in a
12-month period which is calculated as the 12-month period measured forward from the date of your first
federal FMLA leave usage.
You have a ri
ght under the federal FMLA for up to 26 workweeks of leave (unpaid or paid using accruals) in a
single 12-month period to care for a covered servicemember or a covered veteran with a serious injury or illness.
This single 12-month period commences on the first day that you take leave for this purpose.
You have a ri
ght under the state FMLA for up to 16 workweeks of leave (unpaid or paid using accruals) in a 24-
month period which is calculated as the 24-month period measured forward from the date of your first state
FMLA leave usage.
You have a ri
ght under the state FMLA for up to 26 workweeks of leave (unpaid or paid using accruals) in a
single 24-month period to care for a covered servicemember or a covered veteran with a serious injury or illness.
This single 24-month period commences on the first day that you take leave for this purpose.
Your health be
nefits must be maintained during any period of unpaid federal or state family/medical leave under
the same conditions as if you continued to work.
You must b
e reinstated to the same or an equivalent job with the same pay, benefits, and terms and conditions of
employment on your return from federal or state family/medical leave. If your leave extends beyond the end of
your federal FMLA leave entitlements, you do not have return rights under federal FMLA. If you leave extends
beyond the end of your state FMLA leave entitlements, you do not have return rights under state FMLA.
If you do not re
turn to work following federal or state family/medical leave for a reason other than: 1) the
continuation, recurrence, or onset of a serious health condition which would entitle you to leave; 2) the
continuation, recurrence, or onset of a covered servicemember’s serious injury or illness which would entitle you
to leave; or 3) other circumstances beyond your control, you may be required to reimburse the State for the
employer’s share of health insurance premiums paid on your behalf during your family/medical leave.
You have the right to have vacation, personal leave or compensatory leave run concurrently with your federal or
state family/medical leave entitlement, provided you meet any applicable requirements of the leave policies. If
you do not meet the requirements for taking paid leave, you remain entitled to take unpaid federal or state
family/medical leave.
Please review General Letter 39 - State of Connecticut Family and Medical Leave Entitlements
Policy - Revised for additional information about employees' rights and responsibilities under all
of the Family and Medical Leave Entitlements, including the SEBAC Supplemental leave,
pregnancy disability leave, and organ and bone marrow donor leave.
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