This form provided by the Department of Administrative Services
State of
Connecticut Human Resources
Intent to Return to Work
From a Family and Medical Leave Entitlement
(To be completed by the employee and returned to the agency Human Resources
Office b
efore the leave begins, absent extentuating circumstances)
Form #: FMLA - HR3
Revision Date: 3/2018
_________________________________________________________________________________________________
Employee Name _____________________________ Employee No. ______________________________
Official Job Title _____________________________ Agency ___________________________________
I hereby confirm my intent to return to work at the conclusion of my approved leave. ____________
(Fill in “yes” or “no”)
The projected end date of my leave is _______________________________________________.
________________________________________________ ______________________________
(Employee Signature) (Date)
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