Form Fmla-Hr1-Employee Request - Department Of Administrative Services Form 2009

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State of Connecticut Human Resources
Employee Request
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 Employee)
Form #: FMLA-HR1
Revision Date: 3/2009
_________________________________________________________________________________________
Please read carefully the information regarding your family/medical leave entitlements under federal (FMLA) and state
(C.G.S. 5-248a) law. Then complete this form (pages 1 – 4) and return it to your agency’s Human Resources Unit. Be sure to attach or
provide promptly any required documentation.
Under federal FMLA, employees are entitled to take up to 12 weeks of unpaid leave in a 12-month period provided they meet eligibility
and reason for leave requirements. Additionally, permanent state employees have an entitlement of up to 24-weeks family medical leave
in a two-year period. You may be eligible for leave under one or the other law, under both or none. Depending upon several factors, if
you are eligible under both and the reason for leave qualifies under both laws, the leave may count simultaneously toward both
entitlements.
Military Family Leave: Eligible employees who are family members of covered servicemembers will be able to take up to 26 workweeks
of unpaid federal FMLA leave in a “single 12-month period” to care for a covered servicemember with a serious illness or injury incurred
in the line of duty on active duty and/or up to 12 workweeks of unpaid federal FMLA because of any qualifying exigency arising out of
the fact that employee’s spouse, son, daughter, or parent is a covered military member on active duty (or has been notified of an
impending call or order to active duty) in support of a contingency operation.
Note:
A leave request based on an employee’s serious health condition or the serious health condition of an employee’s spouse, child
or parent must be accompanied by a verifying medical certification from a licensed physician or other “healthcare provider.”
(Form P-33A—Employee or Form P-33B—Caregiver)
Note:
A leave request for “military family leave” must be accompanied by a certification (Form DOL-WH384 – Certification of
Qualifying Exigency or Form DOL-WH385 Certification for Serious Injury or Illness of Covered Servicemember).
Employee Name __________________________________ Employee No. ____________________________
Title ____________________________________________ Supervisor _______________________________
Employee’s Home Phone No.________________________ Supervisor’s Phone No. ____________________
Work Location ___________________________________ Shift _____________Hours _________________
Home Address ___________________________________ City _____________________________________
State ____________________________________________ Zip Code ________________________________
Reason for Request: (Check reason)
_____ birth of your child
_____ adoption of a child by you
_____ placement of a foster child with you (Federal FMLA only)
_____ a serious health condition/serious illness that makes you unable to perform the essential functions of your job
_____ a serious health condition/serious illness affecting your (check one)
_____ spouse _____ child _____ parent for which you are needed to provide care
_____ to serve as an organ or bone marrow donor (state only)
_____ Military Family Leave – because of a qualifying exigency arising out of the fact that your ______ spouse;
________ son or daughter; ________parent is on active duty or call to active duty status in support of a
contingency operation as a member of the National Guard or Reserves.
_____ Military Family leave – because you are the _______ spouse; _______ son or daughter; ______ parent:
_______ next of kin of a covered service member with a serious injury or illness.
This form provided by the Department of Administrative Services

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