Core Ct Coding For Leave Of Absence Under The Federal Family And Medical Leave Act (Fmla) - State Of Connecticut Human Resources

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State of Connecticut Human Resources

CORE CT Coding

For Leave of Absence under the Federal Family and Medical Leave Act (FMLA)

And/or State C.G.S. 5-248a (Family and medical leave from employment)

(To be completed by the Human Resources Unit)

Form #: FMLA-HR2c

Revision Date: 3/2015

____________________________________________________________________________________________________________

This form is to be completed by Human Resources when the employee has been approved for federal FMLA and/or state C.G.S.5-

248a leave entitlement and is attached to the employee’s HR2b – Designation Notice. This form can also be used when a workers’

compensation absence is counted against the employee’s federal FMLA entitlement.

Employee Name: ____________________________________ Agency: __________________Date:_________

Employee ID Number: __________________Supervisor’s Name: ____________________________________

The following is a list of CORE CT codes and timeframes to be used for your leave entitlement. Remember: When

calling in, you must specify “FMLA”.

You have been approved for: (check items that apply)

____ Federal FMLA: ____ Intermittent; ____ Reduced Schedule; ____Block Leave; ____Workers Compensation

____ Self; ____ Caregiver; _____ MFL Caregiver Covered Servicemember; _____MFL Caregiver

Covered Veteran; _____ MFL Qualifying Exigency

From __________________________To ____________________________

____ Both federal FMLA and state family medical leave (C.G.S. 5-248a)

_____ Self; _____ Caregiver; _____ MFL Caregiver Covered Servicemember

From _________________________ To ___________________________

____ State family medical leave (C.G.S. 5-248a)

_____ Self; _____ Caregiver; _____MFL Caregiver Covered Servicemember

From _________________________To _____________________________

____ C.G.S. 46a-60(a) (7) – Pregnancy Disability Leave (Use if employee does not qualify for federal

or state family medical leave.

From _________________________ To ___________________________

CORE Code

Description

From

Priority

ADDITIONAL INFORMATION:

PLEASE NOTE: This will be the only REMINDER of your family and medical leave (federal FMLA or state C.G.S. 5-248a) end date. If you require continued leave

or additional leave when your leave entitlement expires, it is your responsibility to submit a new medical certificate (P33a or P33b) in conjunction with an anticipated

absence. Approval shall not be retroactively applied if leave documents are not received timely.

Cc: Human Resources, Payroll, Manager/Supervisor