Form Fmla-Hr1-Employee Request - Department Of Administrative Services Form 2009 Page 4

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HR1-Page 4
Intermittent*/Reduced Schedule Leave** (Federal FMLA only):
Under federal FMLA, under certain conditions, leave can be taken intermittently or on a reduced leave schedule for:
•
A “serious health condition” (child, spouse’s, parent’s or employee’s).
•
Military Family Leave – to care for a covered servicemember with a “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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