1
State of Connecticut Human Resources
Notice of Eligibility and Rights and Responsibilities
regarding Employee Request for Medical Leave, Family Leave or Military Family Leave
(To be completed by the Human Resources Office)
Form #: FMLA-HR2a
Revision Date: 12/2017
This form will:
• Notify you if you meet the eligibility criteria for one or more of the family/medical leave and military
family leave benefits created by federal and state statute, state policy and collective bargaining
agreements;
• Notify you of the information you need to provide to Human Resources to support your request for
leave;
• Advise you of the rights and responsibilities you will have if you are approved to take leave.
This form does not constitute an approval of your leave request.
After Human Resources receives the information from you as specified below, you will receive a
designation notice, telling you if:
• Your leave has been approved, and if so, whether it counts toward one or more of the family/medical
leave and military family leave benefits created by federal and state statute, state policy and collective
bargaining agreements, and how any accrued paid leave will be used; or
• Your leave has been denied; or
• You need to provide additional information.
This form provides employees with the information regarding their eligibility for federal FMLA leave and their rights and
responsibilities for taking federal FMLA leave as required by 29 C.F.R. 825.300(b), (c).
PART A: NOTICE OF ELIGIBILITY
TO: _____________________________________________________
_________________________
(Employee Name)
(Agency)
FROM: __________________________________________________
_________________________
(Agency Human Resources Representative)
(Telephone Number)
DATE: ________________________________
On ________________, you notified us of your need to take family/medical leave or military family leave.
Requested Dates of Leave: From______________________________ To___________________________________
This form provided by the Department of Administrative Services