Employee Request For Leave Of Absence Under The Federal Family And Medical Leave Act - State Of Connecticut Human Resources
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State of Connecticut Human Resources
Employee Request
For Medical Leave, Family Leave or Military Family Leave
For information about specific leave entitlements, contact your Human Resources Office
(To be completed by Employee)
Form #: FMLA-HR1
Revision Date: 12/2017
Employee Name _____________________________ Employee No. _____________________________
Official Job Title ____________________________ Agency ___________________________________
Supervisor _________________________________
Supervisor Phone No. ______________________
Work Location ______________________________ Shift ____________Hours ____________________
Home Address _________________________________________________________________________
City________________________________________ State ________ Zip Code ____________________
Employee’s Personal Phone No. ____________________________________
Employee’s Personal Email _______________________________________________________________
REASON FOR LEAVE: (
Check reason)
For information about specific leave entitlements, contact your Human Resources Office
Personal Medical Leave
Caregiver Leave
(for your
(care for family member in connection with her disability
own serious health condition):
period related to pregnancy and childbirth, or his or her organ or bone marrow
donation, or other serious health condition):
___ My own illness or injury
__ Spouse
___ Disability period related to my
__ Parent
pregnancy and childbirth
__ Parent-in-law (State FMLA only)
___ Organ donation
__ Child (under age 18 or age 18+ and incapable of self-care due to a
___ Bone marrow donation
disability)
BondingLeave:
Military Family Leave
:
___ Qualifying Exigency arising out of the covered active duty of my
___ Birth of child
spouse, parent, or son or daughter
___ Adoption of child
___ Military Caregiver leave for my spouse, parent, son, daughter or
___ Placement of foster child
next of kin who is a covered servicemember
(Federal and state FMLA only)
___ Military Caregiver leave for my spouse, parent, son, daughter or
next of kin who is a covered veteran (Federal FMLA only)
Does your spouse work for the State? ______
(yes) or ______ (no)
Spouse’s Name: __________________________Spouse’s Agency: ______________________________
If YES:
Will he/she be taking leave for the same purpose?
_______ (yes) ____ (no)
This form provided by the Department of Administrative Services
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