State Of Connecticut Human Resources Employee Request For Leave Of Absence Under The Federal Family And Medical Leave Act (Fmla)
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4State of Connecticut Human Resources
Employee Request
For Leave of Absence under the Federal Family and Medical Leave Act (FMLA)
and/or State C. G. S. 5-248a (Family and medical leave from employment)
(To be completed by Employee)
Form #: FMLA-HR1
Revision Date: 3/2013
_________________________________________________________________________________________
Please read carefully the information regarding your family/medical leave entitlements under federal (FMLA) and state
(C.G.S. 5-248a) law. Then complete this form (pages 1 – 4) and return it to your agency’s Human Resources Unit. Be sure to attach or
provide promptly any required documentation.
Under federal FMLA, employees are entitled to take up to 12 weeks of unpaid leave in a 12-month period provided they meet eligibility
and reason for leave requirements. Additionally, permanent state employees have an entitlement of up to 24-weeks of unpaid family
medical leave in a two-year period. You may be eligible for leave under one or the other law, under both or none. Depending upon several
factors, if you are eligible under both and the reason for leave qualifies under both laws, the leave may count simultaneously toward both
entitlements.
Military Family Leave: Federal: Eligible employees who are family members of covered servicemembers (including covered veterans)
will be able to take up to 26 workweeks of unpaid federal FMLA leave in a “single 12-month period” to care for a covered servicemember or
a covered veteran with a covered serious illness or injury incurred or aggravated in the line of duty on covered active duty and/or up to 12
workweeks of unpaid federal FMLA leave because of any qualifying exigency arising out of the fact that employee’s spouse, son, daughter,
or parent is a covered servicemember on covered active duty. State: Eligible employees will be able to take up to 26 weeks of unpaid leave
in a two-year period to care for an immediate family member or next of kin who is a current member of the US Armed Forces, National
Guard or military reserves and is undergoing medical treatment, recuperation or therapy, an inpatient, or on the temporary disability retired
list for a serious illness or injury. Under both state and federal law, an employee can take caregiver leave only one time per covered
servicemember, per injury.
Note:
A leave request based on an employee’s serious health condition or the serious health condition of an employee’s spouse, child
or parent must be accompanied by a verifying medical certification from a licensed physician or other “healthcare provider.”
(Form P-33A—Employee or Form P-33B—Caregiver)
Note:
A leave request for “military family leave” must be accompanied by a certification (Form DOL-WH384 – Certification of
Qualifying Exigency; Form DOL-WH385 Certification for Serious Injury or Illness of Current Servicemember; or
Form DOL-WH385-V Certification for Serious Injury or Illness of a Veteran).
Employee Name __________________________________ Employee No. ____________________________
Title ____________________________________________ Supervisor _______________________________
Employee’s Home Phone No.________________________ Supervisor’s Phone No. ____________________
Work Location ___________________________________ Shift _____________Hours _________________
Home Address ___________________________________ City _____________________________________
State ____________________________________________ Zip Code ________________________________
Reason for Request: (Check reason)
_____ birth of your child
_____ adoption of a child by you
_____ placement of a foster child with you (federal only)
_____ a serious health condition/serious illness that makes you unable to perform the essential functions of your job
_____ a serious health condition/serious illness affecting your (check one)
_____ spouse _____ child _____ parent for which you are needed to provide care
_____ to serve as an organ or bone marrow donor (state only)
_____ Military Family Leave – because of a “qualifying exigency” (federal only) arising out of the fact that
your ______ spouse; ________ son or daughter; ________parent is on covered active duty.
This form provided by the Department of Administrative Services
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