Employee Request For Leave Of Absence Under The Federal Family And Medical Leave Act - State Of Connecticut Human Resources Page 3

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Fill In Chart: You must designate the number of days, or hours, or you may indicate “ALL available.”
Sick Leave
Vacation
Personal
Comp Time Sick Family
Parental
USE OF
Accruals
Accruals
Leave
Days (based
Days (based
on bargaining
on bargaining
ACCRUALS
unit contract)
unit contract)
REASON
Days/Hours
Days/Hours Days/Hours Days/Hours Days/Hours
Days/Hours
PERSONAL MEDICAL LEAVE
My own illness or
Not Applicable
Not Applicable
injury
Disability period related
Not Applicable
Not Applicable
to my pregnancy &
childbirth
Organ donation
Not Applicable
Not Applicable
(after
exhaustion of paid leave
entitlement of 15 days)
Bone marrow
Not Applicable
Not Applicable
donation
(after
exhaustion of paid leave
entitlement of 7 days)
CAREGIVER LEAVE
Spouse
Not Applicable
(including
providing care to your wife
during the disability period
associated pregnancy and
childbirth)
Not Applicable
Parent
Parent-in-law
Not Applicable
Not Applicable
Child
Not Applicable
BONDING LEAVE
Birth of child
Not Applicable
Adoption of child
Not Applicable
Placement of foster
Not Applicable
Not Applicable
child
This form provided by the Department of Administrative Services

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