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 3
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You are required to use your paid sick leave accruals during your pregnancy disability leave.
•
_____ You have requested to use paid leave accruals during your leave. Any paid leave taken for this reason will
count against your pregnancy disability 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 pregnancy disability 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:
_________________________________________________________________________________
See Form FMLA-HR2c for more information about coding your time.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
____ Leave under the 2017 SEBAC Agreement has been approved and all leave taken for this reason
will be designated as “SEBAC Supplemental leave.”
•
Your SEBAC Supplemental leave will begin/began _________________________________.
•
_____ You have requested to use paid leave accruals during your leave. Any paid leave taken for this reason will
count against your SEBAC Supplemental 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 SEBAC Supplemental 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 SEBAC Supplemental 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.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
____ Bone Marrow or Organ Donation leave has been approved.
(Available after January 1, 2018)
•
Your bone marrow or organ donation leave entitlement will begin/began on (date) ________________________
and will end on ____________.
•
You must notify us as soon as practicable if the dates of scheduled leave change or are extended, or were initially
unknown.
See Form FMLA-HR2c for more information about coding your time.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Fitness for Duty: You will be required to return page 4 of the Medical Certificate (Form P33a)
_______
certifying your fitness-for-duty prior to being restored to employment. If such certification is not timely received, your
return to work may be delayed until certification is provided.
A list of the essential functions of your position ____ is ____ is not attached
.
If attached, the fitness-for-duty certification must address your ability to perform these functions.
Note: Failure to return to work at the end of your leave period may be treated as a resignation unless an
extension has been requested, agreed upon and approved in writing by the agency.
This form provided by the Department of Administrative Services
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