State 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: 2/2009
_________________________________________________________________________________________
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 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: Eligible employees who are family members of covered servicemembers 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 with a serious illness or injury incurred
in the line of duty on active duty and/or up to 12 workweeks of unpaid federal FMLA because of any qualifying exigency arising out of
the fact that employee’s spouse, son, daughter, or parent is a covered military member on active duty (or has been notified of an
impending call or order to active duty) in support of a contingency operation.
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 or Form DOL-WH385 Certification for Serious Injury or Illness of Covered Servicemember).
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 FMLA 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 arising out of the fact that your ______ spouse;
________ son or daughter; ________parent is on active duty or call to active duty status in support of a
contingency operation as a member of the National Guard or Reserves.
_____ Military Family leave – because you are the _______ spouse; _______ son or daughter; ______ parent:
_______ next of kin of a covered service member with a serious injury or illness.
This form provided by the Department of Administrative Services
HR1 - Page 2
Duration of Leave: (from) _________________________________ (to) _______________________
(month/day/year) (month/day/year)
Does your spouse work for the State?_______ (yes) or ______ (no)
If yes, which agency? ______________________________________________________________.
If yes, will he/she be taking leave for the same purpose? _______ (yes) _____(no)
Use of Accruals (check as applicable)
(1) Birth of Your Child
(a) Mother – Your absence for the “disability” portion of your pregnancy will automatically be charged to any accrued sick leave.
Once you have exhausted your sick leave, you may use personal leave, vacation accruals, comp time or unpaid leave. Once
you have completed the “disability” portion of your pregnancy (i.e., you have been certified as able to perform the requirements
of your job by your attending physician), you may not use accrued sick leave. You may, however, as above, use personal leave,
vacation accruals, and/or comp time for the balance of your leave. This election must be made before you begin your leave.
If you do not elect to substitute personal leave, vacation accruals or comp time, the leave will be unpaid.
(Answer “yes” or “no) _____ I elect to use vacation, personal and/or comp time leave accruals.
If “yes”, fill in the amount of time you wish to use.
Vacation Accruals: _____________________________________________________________
Personal Leave: _____________________________________________________________
Comp Time Leave Accruals: _____________________________________________________________
(b) Father – You may elect to substitute 3 - 5 days of sick family leave depending on your collective bargaining contract,
personal leave ,vacation accruals and/or comp time for unpaid leave.
(Answer “yes” or “no”) _____ I elect to use sick family days to which I am entitled.
(Answer “yes” or “no”) _____ I elect to use vacation, personal and/or comp time leave accruals.
If “yes,” fill in amount of time you wish to use.
Sick Family Days: ______________________________________________________________
Vacation Accruals: ______________________________________________________________
Personal Leave: ______________________________________________________________
Comp Time Leave Accruals: ______________________________________________________________
(2) Adoption (both State & Federal) or placement of a foster child with you (Federal FMLA only)
You may elect to substitute up to 3 days of sick leave depending on your collective bargaining contract, personal leave,
vacation accruals and/or comp time for unpaid leave.
(Answer “yes” or “no”) ______ I elect to use sick family days to which I am entitled.
(Answer “yes” or “no”) ______ I elect to use vacation, personal and/or comp time leave accruals.
If “yes,” fill in amount of time you wish to use.
Sick Family Days: ______________________________________________________________
Vacation Accruals: _____________________________________________________________
Personal Leave: ______________________________________________________________
Comp Time Leave Accruals: ______________________________________________________________
(3) Employee’s Own “Serious Health Condition”/”Serious Illness”
Absences for your own “serious health condition”/”serious illness,” will be charged to your sick leave. Once
your sick leave accrual has been exhausted, your 24-week state entitlement period will begin and you will have
the option to use, personal leave, vacation accruals and/or comp time balances. This election must be made before you
begin your absence period; personal, vacation and comp time cannot be used to extend the leave entitlement. (Your
federal FMLA entitlement period will begin at the onset of your absence period.)
(Answer “yes” or “no”) ______ I elect to use vacation, personal and/or comp time leave accruals.
If “yes,” fill in amount of time you wish to use.
Vacation Accruals: ________________________________________________________________
Personal Leave: ________________________________________________________________
Comp Time Leave Accruals: ________________________________________________________________
If requesting “intermittent leave” or “reduced leave schedule”, complete page 4.
This form provided by the Department of Administrative Services
HR1 – Page 3
(4) “Serious Health Condition”/”Serious Illness” of Spouse, Child, Parent
If your absence is to provide care for a spouse, child or parent with a “serious health condition”/ “serious
illness, you are entitled to use 3 to 5 days of sick leave per year for a family emergency, depending on your
collective bargaining contract. After that time, you may elect to use personal leave, vacation accruals, and/or
comp time. This election must be made before you begin your absence and this time cannot be used to extend
the leave entitlement.
(Answer “yes” or “no”) ______ I elect to use any remaining days of sick family leave which I am entitled.
(Answer “yes” or “no”) ______ I elect to use vacation, personal and/or comp time leave accruals.
If “yes,” fill in amount of time you wish to use.
Sick Family Days: ______________________________________________________________
Vacation Accruals: ______________________________________________________________
Personal Leave: ______________________________________________________________
Comp Time Leave Accruals: _______________________________________________________
If requesting “intermittent leave” or “reduced leave schedule”, complete page 4.
(5) Serve as an organ or bone marrow donor (state only)
You may elect to substitute personal leave, vacation accruals and/or comp time for unpaid leave. This election
must be made before you begin your absence.
(Answer “yes” or “no) ______ I elect to use vacation, personal and/or comp time leave accruals.
If “yes,” fill in amount of time you wish to use.
Vacation Accruals: ______________________________________________________________
Personal Leave: ______________________________________________________________
Comp Time Leave Accruals: _______________________________________________________
(6) Military Family Leave: “Serious Injury or Illness of a Covered Servicemember”
If your absence is to provide care for a covered servicemember with a “serious injury or illness”, who is a member of
your immediate family, as defined in your collective bargaining contract or other policies, you are entitled to use
3-5 days of sick leave per year for a family emergency. After that time, you may elect to use personal leave, vacation
accruals and/or comp time for unpaid leave. This election must be made before you begin your absence.
(Answer “yes” or “no”) ______I elect to use any remaining days of sick leave which I am entitled.
(Answer “yes” or “no”) _____ I elect to use vacation, personal, and/or comp time leave accruals.
If “yes,” fill in the amount of time you wish to use.
Sick Family Days: _____________________________________________________________
Vacation Accruals: _____________________________________________________________
Personal Leave: _____________________________________________________________
Comp Time Leave Accruals: _____________________________________________________
If requesting “intermittent leave” or “reduced leave schedule”, complete page 4.
(7) Military Family Leave: “Qualifying Exigency”
If your absence is because of a “qualifying exigency” arising out of the fact that your spouse, son, daughter, or parent
is a covered military member on active duty in support of a contingency operation, your leave is unpaid. For use of
vacation leave accruals, personal leave or comp time, you must follow your collective bargaining contract or other
policies. If granted per contract or policy, the election must be made before you begin your absence.
(Answer “yes” or “no”) ________ I elect to use vacation, personal and/or comp time leave accruals.
If “yes,” fill in the amount of time you wish to use.
Vacation Accruals: _____________________________________________________________
Personal Leave: _____________________________________________________________
Comp Time Leave Accruals: ______________________________________________________
If requesting “intermittent leave” or “reduced leave schedule”, complete page 4.
This form provided by the Department of Administrative Services
HR1-Page 4
Intermittent*/Reduced Schedule Leave** (Federal FMLA only):
Under federal FMLA, under certain conditions, leave can be taken intermittently or on a reduced leave schedule for:
• A “serious health condition” (child, spouse’s, parent’s or employee’s).
• Military Family Leave – to care for a covered servicemember with a “serious illness or injury”.
• Military Family Leave – because of a “qualifying exigency”.
State family/medical leave law (C.G.S. 5-248a) contains no provision for intermittent or reduced leave. However, General Letter
No. 217-A outlines the procedures under which a full-time employee may return from a medical or maternity leave on a part-time
basis.
(Answer “yes” or “no”) ________ I am requesting authorization for “intermittent leave”*, or
(Answer “yes” or “no”) ________ I am requesting authorization for “reduced leave” schedule”.**
If yes, explain. ___________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________________
* “Intermittent leave” is leave taken in separate blocks of time due to a single qualifying reason.
** “Reduced leave schedule” is a leave schedule that reduces an employee’s usual number of working hours per work-week,
or hours per workday. It is a change in the employee’s schedule for a period of time, normally from full-time to part-time.
I understand that a failure to return to work at the end of my leave period may be treated as a resignation unless an
extension has been requested, agreed upon and approved in writing by the agency.
____________________________________________________ _________________________
(Employee Signature/Agency) (Date)
Return the completed form(s) to your agency human resources department:
Bonnie Price
Attention: ______________________________________________________
Central Connecticut State University
Agency: _______________________________________________________
1615 Stanley Street
Address: _______________________________________________________
New Britain, CT 06050-4010
_______________________________________________________
This form provided by the Department of Administrative Services