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 Page 2
Download a blank fillable 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 in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete 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 with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
72
PART A: APPROVED LEAVES
You are approved to take leave under one or more of the following leave entitlements:
____ Leave under federal FMLA has been approved and all leave taken for this reason will be
designated as federal FMLA leave.
•
Your annual federal leave entitlement will begin/began on (date) _________________________________.
•
Your federal FMLA leave will run concurrently with a worker’s compensation leave. _____ Yes _____ No
•
Your spouse ____ works/_____does not work for the State of Connecticut.
He/she _____will/_____will not be taking leave for the same purpose.
o
•
You are required to use your paid sick leave accruals if the absence is for your own serious illness.
•
_____ You have requested to use paid leave accruals during your leave. Any paid leave taken for this reason will
count against your federal FMLA leave entitlement. (See pages 6 and 7)
•
You are required to notify us as soon as practicable if the dates of scheduled leave change or are extended,
or were initially unknown. Based on the information you have provided to date, we are providing the following
information about the amount of time that will be counted against your federal FMLA leave entitlement:
_____ Provided there is no deviation from your anticipated leave schedule, the following number of
hours, days, or weeks will be counted against your leave entitlement:
_________________________________________________________________________________
_____ Because the leave you will need will be unscheduled, it is not possible to provide the hours,
days, or weeks that will be counted against your federal FMLA entitlement at this time. You have the
right to request this information once in a 30-day period (if leave was taken in the 30-day period).
See Form FMLA-HR2c for more information about coding your time.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
____ Leave under C.G.S. 31-51kk has been approved and all leave taken for this reason will be
designated as “state FMLA leave.”
•
Your annual state leave entitlement will begin/began on (date) _________________________________.
•
Your state FMLA leave will run concurrently with a worker’s compensation leave. _____ Yes _____ No
•
Your spouse ____ works/_____does not work for the State of Connecticut.
He/she _____will/_____will not be taking leave for the same purpose.
o
•
You are required to use your paid sick leave accruals if the absence is for your own serious illness.
•
_____ You have requested to use paid leave accruals during your leave. Any paid leave taken for this reason will
count against your federal FMLA leave entitlement. (See pages 6 and 7)
•
You are required to notify us as soon as practicable if the dates of scheduled leave change or are extended,
or were initially unknown. Based on the information you have provided to date, we are providing the following
information about the amount of time that will be counted against your federal FMLA leave entitlement:
_____ Provided there is no deviation from your anticipated leave schedule, the following number of
hours, days, or weeks will be counted against your state FMLA leave entitlement:
_________________________________________________________________________________
_____ Because the leave you will need will be unscheduled, it is not possible to provide the hours,
days, or weeks that will be counted against your state FMLA entitlement at this time. You have the
right to request this information once in a 30-day period (if leave was taken in the 30-day period).
See Form FMLA-HR2c for more information about coding your time.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
____ Leave under C.G.S. 46a-60(a)(7) leave has been approved and all leave taken for this reason
will be designated as “pregnancy disability leave.”
•
Your pregnancy disability leave entitlement will begin/began on (date) _________________________________.
This form provided by the Department of Administrative Services
ADVERTISEMENT
0 votes
Related Articles
Related forms
State Of Connecticut Human Resources Employee Request For Leave Of Absence Under The Federal Family And Medical Leave Act (fmla)
Business
Employee Request For Leave Of Absence Under The Federal Family And Medical Leave Act - State Of Connecticut Human Resources
Business
Core Ct Coding For Leave Of Absence Under The Federal Family And Medical Leave Act (fmla) - State Of Connecticut Human Resources
Business
Form 2700 - L-4169 Application For Property Tax Relief During Active Military Service As Permitted Under The Federal Soldiers And Sailors Relief Act
Financial
Family Medical Leave Act Employee Request For Leave Form - Leander Independent School District
Business
Related Categories
Parent category: Business