Form Fmla-Hr2a - Notice Of Eligibility And Rights And Responsibilities - State Of Connecticut Human Resources Page 3

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Supplemental Leave under SEBAC 2017:
To qualify for supplemental leave, you must be a “permanent” employee as defined in C.G.S. 5-196(19).
________ You are eligible for supplemental leave. (See Parts B & C)
________ Are not eligible for supplemental leave because
_____
You are an employee in classified service who has not successfully completed your required initial working test period.
______
You are an employee in unclassified service who has not served in your position for at least six (6) months.
Pregnancy Disability Leave (C.G.S. 46a-60(a)(7)):
_______ Pursuant to C.G.S. 46a-60(a)(7) you are entitled to take a reasonable leave of absence for the disability resulting from
your pregnancy.
Bone Marrow or Organ Donation leave (
):
available after January 1, 2018
_______ As a state employee you are eligible to take leave up to 15 days for organ donation and up to 7 days for bone marrow
donation.
PART B: DOCUMENTATION NEEDED TO ASSESS YOUR LEAVE REQUEST
As indicated above, you meet the eligibility requirements for one or more of the family/medical leave or military family leave
entitlements available to employees of the State of Connecticut. In order for us to determine whether the reason for your leave
qualifies under the family/medical leave or military family leave entitlements available to employees of the State of Connecticut, the
agency Human Resources Office needs additional information.
You must return the following documentation to Human Resources by ___________________________ (date). (Check all that apply)
_____
Form P33a – Employee - To substantiate the employee’s own “serious health condition” – including pregnancy.
_____ Form P33b – Caregiver -To substantiate that the employee is needed to care for a spouse, child, parent, or parent-in-law with a
“serious health condition”.
______ Bonding with a newborn child - A written statement asserting that the requisite family relationship exists, or other documentation such
as a child’s birth certificate or a court document.
______ Adoption - A written statement asserting that the requisite family relationship exists, or other documentation such as child’s adoption
papers or a court document.
______ Placement of a foster child with you – A written statement asserting that the requisite family relationship exists, or other
documentation, such as a letter from the state establishing placement date.
______ Form DOL-WH384 – Certification of Qualifying Exigency for Military Family Leave.
______ Form DOL-WH385 - Certification for Serious Injury or Illness of Current Servicemember for Military Caregiver Leave.
______ Form DOL-WH385-V – Certification for Serious Injury or Illness of a Veteran for Military Caregiver Leave.
______ Documentation to establish the required relationship between you and your family member.
______ No additional certification documentation is requested.
If sufficient documentation is NOT provided in a timely manner, your leave may be denied.
You will also need to submit the following completed forms: (Check all that apply)
______ FMLA- HR1 – Employee Request for Leave of Absence
______ FMLA- HR3 – Intent to Return to Work
This form provided by the Department of Administrative Services

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