Employee Request For Leave Of Absence Under The Federal Family And Medical Leave Act - State Of Connecticut Human Resources Page 2
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TYPE OF LEAVE REQUESTED:
(Check all that apply)
Block Leave:
A continuous absence for a single qualifying reason (e.g., one month).
Reduced Schedule Leave:
A leave schedule that changes the employee’s normal work schedule for a
period of time by reducing the employee’s usual number of working hours per workweek or hours per day.
Intermittent Leave:
Leave taken in separate blocks of time due to a single qualifying reason.
NOTE:
Intermittent leave and reduced schedule leave are not available in all situations. Availability of these types of leave depends upon
the reason for leave and your eligibility for specific leave entitlements. Contact your Human Resources Department for more
information.
Duration of Leave
:
_________________________________ (to) _______________________
(from)
(month/day/year)
(month/day/year)
Please describe your leave request:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
REQUESTED USE OF ACCRUALS:
•
The choice to use your accruals during your absence must be made before you begin your leave.
o If you want to change your accrual designation, you must contact your Human Resources Office.
o Accrual changes will be applied prospectively.
•
If the reason is for your own personal medical leave:
o Sick leave accruals must be used.
o Sick leave accruals must be exhausted before other earned accruals can be used.
•
If you do not elect to use your accruals, the leave will be unpaid.
•
If you choose not to use all of your accruals or if your accruals are exhausted before the leave ends,
the remainder of the leave will be unpaid.
•
If you elect to use your accruals, that paid time must be spent down completely before you go into unpaid
status.
•
You cannot intermingle unpaid time with paid time.
•
Depending upon the reason for leave and your eligibility for specific leave entitlements, you may be allowed
to use sick leave accruals for leave associated with bonding with a newborn child or newly placed adoptive
child and for caregiver leave. Your Human Resources Office will notify you if you meet the criteria for use
of sick leave accruals for these reasons.
This form provided by the Department of Administrative Services
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