Employee Request For Leave Of Absence Under The Federal Family And Medical Leave Act - State Of Connecticut Human Resources Page 4

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Sick Leave
Vacation
Personal
Comp Time
Sick Family
Parental
USE OF
Accruals
Accruals
Leave
Days (based
Days (based
on bargaining
on
ACCRUALS
unit contract)
bargaining
unit contract)
REASON
Days/Hours
Days/Hours Days/Hours
Days/Hours
Days/Hours
Days/Hours
MILITARY FAMILY LEAVE
Military Caregiver -
Not
Applicable
Covered Servicemember
Military Caregiver -
Not
Applicable
Covered Veteran
Qualifying Exigency
Not Applicable
Not
Applicable
leave
____________________________________________________
_______________
(Employee Signature)
(Date)
Return the completed form(s) to your agency Human Resources Office.
This form provided by the Department of Administrative Services

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