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 6

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Based on the information you provided to date, your accruals will be used as follows:
Sick Leave
Vacation
Personal
Comp Time
Sick Family
Parental
Days (based
Days (based
USE OF
Accruals
Accruals
Leave
Accruals
ACCRUALS
on bargaining
on bargaining
unit contract)
unit contract)
REASON
Days/Hours
Days/Hours Days/Hours Days/Hours Days/Hours
Days/Hours
PERSONAL MEDICAL LEAVE
If available,
Not Applicable
Not Applicable
My own illness or
must be used
injury
Disability period related
If available,
Not Applicable
Not Applicable
to my pregnancy &
must be used
childbirth
Organ donation
If available,
Not Applicable
Not Applicable
(after
must be used
exhaustion of paid leave
entitlement of 15 days)
If available,
Not Applicable
Not Applicable
Bone marrow
must be used
donation
(after
exhaustion of paid leave
entitlement of 7 days)
CAREGIVER LEAVE
Spouse
Not Applicable
(including
providing care to your wife
during the disability period
associated pregnancy and
childbirth)
Parent
Not Applicable
Not Applicable
Not Applicable
Parent-in-law
Child
Not Applicable
BONDING LEAVE
Birth of child
Not Applicable
Adoption of child
Not Applicable
Placement of foster
Not Applicable
Not Applicable
child
This form provided by the Department of Administrative Services

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