Form Fmla-Hr1-Employee Request - Department Of Administrative Services Form 2009 Page 3
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4HR1 – Page 3
(3) Employee’s Own “Serious Health Condition”/”Serious Illness”
Absences for your own “serious health condition”/”serious illness,” will be charged to your sick leave. Once your sick leave
accrual has been exhausted, your 24-week state entitlement period will begin and you will have the option to use, personal
leave, vacation accruals and/or comp time balances. This election must be made before you begin your absence period, personal
vacation and comp time cannot be used to extend the leave entitlement
(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.
Vacation Accruals:
________________________________________________________________
Personal Leave:
________________________________________________________________
Comp Time Leave Accruals: ________________________________________________________________
If requesting “intermittent leave” or “reduced leave schedule”, complete page 4.
(4) “Serious Health Condition”/”Serious Illness” of Spouse, Child, Parent
If your absence is to provide care for a spouse, child or parent with a “serious health condition”/ “serious illness”, you are
entitled to use 3 to 5 days of sick leave per year for a family emergency, depending on your collective bargaining contract.
After that time, you may elect to use personal leave, vacation accruals, and/or comp time. This election must be made before
you begin your absence and this time cannot be used to extend the leave entitlement.
(Answer “yes” or “no”) ______ I elect to use any remaining days of sick family leave 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.
Sick Family Days: ______________________________________________________________
Vacation Accruals: ______________________________________________________________
Personal Leave:
______________________________________________________________
Comp Time Leave Accruals: _______________________________________________________
If requesting “intermittent leave” or “reduced leave schedule”, complete page 4.
(5) Serve as an organ or bone marrow donor (state only)
You may elect to substitute personal leave, vacation accruals and/or comp time for unpaid leave. This 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 amount of time you wish to use.
Vacation Accruals: ______________________________________________________________
Personal Leave:
______________________________________________________________
Comp Time Leave Accruals: _______________________________________________________
(6) Military Family Leave: “Serious Injury or Illness of a Covered Servicemember”
If your absence is to provide care for a covered servicemember with a “serious injury or illness”, who is a member of your
immediate family, as defined in your collective bargaining contract or other policies, you are entitled to use 3-5 days of sick leave
per year for a family emergency. After that time, you may elect to use personal leave, vacation accruals and/or comp time for
unpaid leave. This election must be made before you begin your absence.
(Answer “yes” or “no”) ______I elect to use any remaining days of sick leave 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.
Sick Family Days: _____________________________________________________________
Vacation Accruals: _____________________________________________________________
Personal Leave:
_____________________________________________________________
Comp Time Leave Accruals: _____________________________________________________
If requesting “intermittent leave” or “reduced leave schedule”, complete page 4.
(7) Military Family Leave: “Qualifying Exigency”
If your absence is because of a “qualifying exigency” arising out of the fact that your spouse, son, daughter, or parent is a covered
military member on active duty in support of a contingency operation, 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 page 4.
This form provided by the Department of Administrative Services
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