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 5

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PART C: LEAVE REQUESTS NOT APPROVED
is denied because
_____ Federal FMLA leave
:
____ The federal FMLA does not apply to your leave.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
____ You have exhausted your federal FMLA leave entitlement in the applicable 12-month period.
State family/medical leave (C.G.S. 31-51kk) is denied because:
______
____ The state family/medical leave does not apply to your leave request.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
____ You have exhausted your state family/medical leave entitlement in the applicable two-year period.
____ Leave under C.G.S. 46a-60(a)(7) is denied because this statute does not apply to your leave
request.
____ SEBAC Supplemental Leave is denied because:
____ SEBAC Supplemental leave does not apply to your leave request.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
____ You have exhausted your SEBAC Supplemental entitlement in the applicable two-year period.
____ Bone Marrow/Organ Donation Leave is denied because this statute does not apply to your
leave request.
PART D: USE OF ACCRUALS
•
The choice to use your accruals must be made before you begin your leave.
o If you want change your accrual designation, you must contact your Human Resources Office.
o Accrual changes will be applied prospectively.
•
If the reason for leave is for your own serious illness:
o Sick leave accruals must be used.
o Sick leave accruals must be exhausted before other accruals can be used.
•
If you do not elect to use your accruals, the leave will be unpaid.
•
If you choose not to use all of your accruals or if your accruals are exhausted before the leave ends,
the remainder of the leave will be unpaid.
•
If you elect to use your accruals, that paid time must be spent down completely before you go into
unpaid status.
•
You cannot intermingle unpaid time with paid time.
This form provided by the Department of Administrative Services

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