State Of Connecticut Human Resources Employee Request For Leave Of Absence Under The Federal Family And Medical Leave Act (Fmla) Page 2
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_____ Military Family Leave – because you are the ____ spouse; _____ son or daughter; _____ parent;
_____next of kin of a _____covered servicemember or _____ covered veteran (federal only)
with a “covered serious injury or illness.”
uration of Leave:
_________________________________ (to) _______________________
D
(from)
(month/day/year)
(month/day/year)
Does your spouse work for the State?_______
(yes) or ______ (no)
? ______________________________________________________________.
If yes, which agency
_______ (yes) _____(no)
If yes, will he/she be taking leave for the same purpose?
Use of Accruals (check as applicable)
(1) Birth of Your Child
(a) Mother – Your absence for the “disability” portion of your pregnancy will automatically be charged to any accrued sick
leave. Once you have exhausted your sick leave, you may use personal leave, vacation accruals, comp time or unpaid leave.
Once you have completed the “disability” portion of your pregnancy (i.e., you have been certified as able to perform the
the requirements of your job by your attending physician), you may not use accrued sick leave. You may, however,
use parental days, personal leave, vacation accruals, and/or comp time depending on your collective bargaining unit
contract for the balance of your leave. This election must be made before you begin your leave. If you do not elect to
substitute parental days, personal leave, vacation accruals or comp time, the leave will be unpaid.
(Answer “yes” or “no”) _____ I elect to use parental days to which I am entitled.
(Answer “yes” or “no”) _____ I elect to use vacation, personal and/or comp time leave accruals.
If “yes”, fill in the amount of time you wish to use.
Parental Days:
_____________________________________________________________
Vacation Accruals:
_____________________________________________________________
Personal Leave:
_____________________________________________________________
Comp Time Leave Accruals: _____________________________________________________________
(b) Father/Spouse–(check) ____Married ____Unmarried. You may elect to substitute 3 - 5 days of sick family leave and/or
parental days depending on your collective bargaining contract, personal leave ,vacation accruals and/or comp time for
unpaid leave.
(Answer “yes” or “no”) _____ I elect to use parental days to which I am entitled.
(Answer “yes” or “no”) _____ I elect to use sick family days to which I am entitled.
(Answer “yes” or “no”) _____ I elect to use vacation, personal and/or comp time leave accruals.
If “yes,” fill in amount of time you wish to use:
Parental Days:
_______________________________________________________________
Sick Family Days:
______________________________________________________________
Vacation Accruals:
______________________________________________________________
Personal Leave:
______________________________________________________________
Comp Time Leave Accruals: ______________________________________________________________
(2) Adoption (both State & Federal) or placement of a foster child with you (federal only)
You may elect to substitute 3 - 5 days of sick leave (parental days) for adoption depending on your collective bargaining
contract, and/or personal leave, vacation accruals, comp time for unpaid leave.
(Answer “yes” or “no”) ______ I elect to use parental days for adoption to which I am entitled.
(Answer “yes” or “no”) ______ I elect to use vacation, personal and/or comp time leave accruals.
If “yes,” fill in amount of time you wish to use.
Parental Days (adoption only): ______________________________________________________________
Vacation Accruals:
______________________________________________________________
Personal Leave:
______________________________________________________________
Comp Time Leave Accruals:
______________________________________________________________
This form provided by the Department of Administrative Services
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