State Of Connecticut Human Resources Employee Request For Leave Of Absence Under The Federal Family And Medical Leave Act (Fmla) Page 4
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(7) Military Family Leave: “Qualifying Exigency” (federal only)
If your absence is because of a “qualifying exigency” arising out of the fact that your spouse, son, daughter, or parent is a covered
servicemember on covered active duty, your leave is unpaid. For use of vacation leave accruals, personal leave or comp time,
you must follow your collective bargaining contract or other policies. If granted per contract or policy, the election must be made
before you begin your absence.
(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.
Vacation Accruals: _____________________________________________________________
Personal Leave:
_____________________________________________________________
Comp Time Leave Accruals: ______________________________________________________
If requesting “intermittent leave” or “reduced leave schedule”, complete the information below.
Intermittent*/Reduced Schedule Leave** (federal only):
Under federal FMLA, under certain conditions, leave can be taken intermittently or on a reduced leave schedule for:
•
A “serious health condition” (child’s, spouse’s, parent’s or employee’s).
•
Military Family Leave – to care for a covered servicemember or covered veteran
with a “covered serious illness or injury.”
•
Military Family Leave – because of a “qualifying exigency.”
State family/medical leave law (C.G.S. 5-248a) contains no provision for intermittent or reduced leave. However, General Letter
No. 217-A outlines the procedures under which a full-time employee may return from a medical or maternity leave on a part-time
basis.
________
(Answer “yes” or “no”)
I am requesting authorization for “intermittent leave”*, or
________
(Answer “yes” or “no”)
I am requesting authorization for “reduced leave” schedule”.**
. ___________________________________________________________________________
If yes, explain
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
*
“Intermittent leave” is leave taken in separate blocks of time due to a single qualifying reason.
** “Reduced leave schedule” is a leave schedule that reduces an employee’s usual number of working hours per work-week,
or hours per workday. It is a change in the employee’s schedule for a period of time, normally from full-time to part-time.
____________________________________________________
_________________________
(Employee Signature/Agency)
(Date)
Return the completed form(s) to your agency human resources department:
Attention: ______________________________________________________
Agency: _______________________________________________________
Address: _______________________________________________________
_______________________________________________________
This form provided by the Department of Administrative Services
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