Agency Response: Designation Notice To Employee Request For Leave Of Absence Under The Federal Family And Medical Leave Act (Fmla) - State Of Connecticut Human Resources
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71
State of Connecticut Human Resources
Designation Notice
Agency Response to Employee Request for Medical Leave, Family Leave or Military Family Leave
(To be completed by the Human Resources Office)
Form # FMLA-HR2b
Revision Date: 12/2017
TO: _________________________________________
_________________________________
(Employee Name)
(Agency)
FROM: ______________________________________
_________________________________
(
Agency Human Resources Representative)
(Telephone Number)
DATE: _______________________________________
REASON FOR LEAVE:
Personal Medical Leave (for your own
Caregiver Leave (care for family member in connection with her disability
serious health condition):
period related to pregnancy and childbirth, or his or her organ or bone
___ My own illness or injury
marrow donation, or other serious health condition):
___ Disability period related to my
__ Spouse
pregnancy and childbirth
__ Parent
___ Organ donation
__ Parent-in-law (State FMLA only)
___ Bone marrow donation
__ Child (under age 18 or age 18+ and incapable of self-care due to a
disability)
Bonding Leave:
Military Family Leave:
___ Birth of child
___ Qualifying Exigency arising out of the covered active duty of your
___ Adoption of child
spouse, parent, or son or daughter
___ Placement of foster child
___ Military Caregiver leave for your spouse, parent, son, daughter or next
(Federal or state FMLA only)
of kin who is a covered servicemember
___ Military Caregiver leave for your spouse, parent, son, daughter or next
of kin who is a covered veteran (Federal FMLA only)
We have reviewed your request for leave and any supporting documentation that you have provided. We received your most recent
information on (date)______________________________________and determined:
___
You are approved to take leave pursuant to one or more of the following leave entitlements:
____
Federal FMLA
____
State FMLA
____
Pregnancy Disability Leave under C.G.S. 46a-60(a)(7)
____
SEBAC Supplemental Leave
____
Bone Marrow or Organ Donation Leave
See pages 2 – 4, & 6 - 8 for critical information about your leave entitlements, responsibilities and accrual usage. You may
be required to provide certification of your fitness for duty at the end of your leave. See page 4 for more information.
___
Additional information is needed in order to determine whether your leave request can be approved.
See page 4 for an explanation of the additional information that will be needed.
___
You are not approved to take leave pursuant to one or more of the following leave entitlements:
____
Federal FMLA
____
State FMLA
____
Pregnancy Disability Leave under C.G.S. 46a-60(a)(7)
____
SEBAC Supplemental Leave
____
Bone Marrow or Organ Donation Leave
See page 5 for an explanation of the reasons for the denials.
This form provided by the Department of Administrative Services
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