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 4

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PART B: ADDITIONAL INFORMATION REQUIRED
Additional information is needed to determine if your leave request can be approved.
Incomplete/Insufficient Certification:
______
The certification you have provided is incomplete or insufficient to determine whether your leave request can be
approved.
You must provide the following information no later than __________________
, unless it is
(provide at least 7 calendar days)
not practicable under the particular circumstances despite your diligent good faith efforts, or your leave may be denied.
Specific information needed to make the certificate complete and sufficient:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Second/Third Opinion:
_______
We are exercising our right to have you obtain a second or third opinion medical certification at our expense,
and we will provide further details at a later date.
This form provided by the Department of Administrative Services

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