1
State of Connecticut Human Resources
CORE CT Coding
For Family and Medical Leave Entitlements
(
To be completed by the Human Resources Office)
Form #: FMLA-HR2c
Revision Date: 3/2018
__________________________________________________________________________________________________________
This form is to be completed by Human Resources when the employee has been approved for federal FMLA, state FMLA, SEBAC
Supplemental leave, pregnancy disability leave, and/or organ or bone marrow donor leave.
It should be given to the employee and the employee’s supervisor and/or manager.
Employee Name: ____________________________________ Agency: __________________Date:_________
Employee ID Number: __________________Supervisor’s Name: ____________________________________
Th
e following is a description of the timeframes of your leave entitlement(s) and a list of the Core-CT codes to use
during your leave.
You have been approved for:
____
Federal FMLA:
____ Intermittent ____ Reduced Schedule ____Block Leave ____Concurrent with WorkersCompensation
Dates: From __________________________To ____________________________
Description of Reduced Schedule and/or Anticipated Frequency and Duration of Intermittent Leave:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
____
State FMLA:
____Intermittent ____Reduced Schedule ____Block Leave ____ Concurrent with WorkersCompensation
Dates: From _________________________To _____________________________
Desc
ription of Reduced Schedule and/or Anticipated Frequency and Duration of Intermittent Leave:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
____ SEBAC 2017 Supplemental Leave:
_____Block Leave ______Reduced Schedule Leave (bonding only)
Dates: From __________________________ To___________________________________
Desc
ription of Reduced Schedule:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
2
____ Pregnancy Disability Leave
Dates: From ________________________ To _____________________________
____ Organ or Bone Marrow Donor Leave
Dates: From ___
_____________________ To _____________________________
CORE Code Description From To
Priority
NOTE: If you require additional leave when your leave entitlement expires, it is your responsibility to
submit a new medical certificate (P33a or P33b) in conjunction with an anticipated absence. Approval
shall not be retroactively applied if leave documents are not received on a timely basis.
cc: Human Resources, Payroll, Manager/Supervisor
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