Form FMLA-HR1 "Employee Request for Family and Medical Leave Entitlements" - Connecticut

What Is Form FMLA-HR1?

This is a legal form that was released by the Connecticut State Department of Administrative Services - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2018;
  • The latest edition provided by the Connecticut State Department of Administrative Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form FMLA-HR1 by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Administrative Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form FMLA-HR1 "Employee Request for Family and Medical Leave Entitlements" - Connecticut

587 times
Rate (4.3 / 5) 35 votes
1
State of Connecticut Human Resources
Employee Request
For Family and Medical Leave Entitlements
For information about specific leave entitlements, contact your Human Resources Office
(To be completed by Employee)
Form #: FMLA-HR1
Revision Date: 3/2018
Employee Name _____________________________ Employee No. _____________________________
Official Job Title ____________________________ Agency ___________________________________
Supervisor _________________________________
Supervisor Phone No. ______________________
Work Location ______________________________ Shift ____________Hours ____________________
Home Address _________________________________________________________________________
City________________________________________ State ________ Zip Code ____________________
Employee’s Personal Phone No. ____________________________________
Employee’s Personal Email _______________________________________________________________
REASON FOR LEAVE: (
Check reason)
For information about specific leave entitlements, contact your Human Resources Office
Personal Medical Leave
Caregiver Leave
(for your
(care for family member in connection with her disability
own serious health condition):
period related to pregnancy and childbirth, or his or her organ or bone marrow
donation, or other serious health condition):
___ My own illness or injury
__ Spouse
___ Disability period related to my
__ Parent
pregnancy and childbirth
__ Parent-in-law (State FMLA only)
___ Organ donor
__ Child (under age 18 or age 18+ and incapable of self-care due to a
___ Bone marrow donor
disability)
BondingLeave:
Military Family Leave
:
___ Qualifying Exigency arising out of the covered active duty of my
___ Birth of child
spouse, parent, or son or daughter
___ Adoption of child
___ Military Caregiver leave for my spouse, parent, son, daughter or
___ Placement of foster child
next of kin who is a covered servicemember
(Federal and state FMLA only)
___ Military Caregiver leave for my spouse, parent, son, daughter or
next of kin who is a covered veteran (Federal FMLA only)
Does your spouse work for the State? ______
(yes) or ______ (no)
Spouse’s Name: __________________________Spouse’s Agency: ______________________________
If YES:
Will he/she be taking leave for the same purpose?
_______ (yes) ____ (no)
This form provided by the Department of Administrative Services
1
State of Connecticut Human Resources
Employee Request
For Family and Medical Leave Entitlements
For information about specific leave entitlements, contact your Human Resources Office
(To be completed by Employee)
Form #: FMLA-HR1
Revision Date: 3/2018
Employee Name _____________________________ Employee No. _____________________________
Official Job Title ____________________________ Agency ___________________________________
Supervisor _________________________________
Supervisor Phone No. ______________________
Work Location ______________________________ Shift ____________Hours ____________________
Home Address _________________________________________________________________________
City________________________________________ State ________ Zip Code ____________________
Employee’s Personal Phone No. ____________________________________
Employee’s Personal Email _______________________________________________________________
REASON FOR LEAVE: (
Check reason)
For information about specific leave entitlements, contact your Human Resources Office
Personal Medical Leave
Caregiver Leave
(for your
(care for family member in connection with her disability
own serious health condition):
period related to pregnancy and childbirth, or his or her organ or bone marrow
donation, or other serious health condition):
___ My own illness or injury
__ Spouse
___ Disability period related to my
__ Parent
pregnancy and childbirth
__ Parent-in-law (State FMLA only)
___ Organ donor
__ Child (under age 18 or age 18+ and incapable of self-care due to a
___ Bone marrow donor
disability)
BondingLeave:
Military Family Leave
:
___ Qualifying Exigency arising out of the covered active duty of my
___ Birth of child
spouse, parent, or son or daughter
___ Adoption of child
___ Military Caregiver leave for my spouse, parent, son, daughter or
___ Placement of foster child
next of kin who is a covered servicemember
(Federal and state FMLA only)
___ Military Caregiver leave for my spouse, parent, son, daughter or
next of kin who is a covered veteran (Federal FMLA only)
Does your spouse work for the State? ______
(yes) or ______ (no)
Spouse’s Name: __________________________Spouse’s Agency: ______________________________
If YES:
Will he/she be taking leave for the same purpose?
_______ (yes) ____ (no)
This form provided by the Department of Administrative Services
2
TYPE OF LEAVE REQUESTED:
(Check all that apply)
Block Leave:
A continuous absence for a single qualifying reason (e.g., one month).
Reduced Schedule Leave:
A leave schedule that changes the employee’s normal work schedule for a
period of time by reducing the employee’s usual number of working hours per workweek or hours per day.
Intermittent Leave:
Leave taken in separate blocks of time due to a single qualifying reason.
NOTE:
Intermittent leave and reduced schedule leave are not available in all situations. Availability of these types of leave depends upon
the reason for leave and your eligibility for specific leave entitlements. Contact your Human Resources Office for more
information.
Duration of Leave
:
_________________________________ (to) _______________________
(from)
(month/day/year)
(month/day/year)
Please describe your leave request:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
REQUESTED USE OF ACCRUALS:
The choice to use your accruals during your absence must be made before you begin your leave.
o If you want to change your accrual designation, you must contact your Human Resources Office.
o Accrual changes will be applied prospectively.
If the reason is for your own personal medical leave:
o Sick leave accruals must be used.
o Sick leave accruals must be exhausted before other earned accruals can be used.
If you do not elect to use your accruals, the leave will be unpaid.
If you choose not to use all of your accruals or if your accruals are exhausted before the leave ends,
the remainder of the leave will be unpaid.
If you elect to use your accruals, that paid time must be spent down completely before you go into unpaid
status.
You cannot intermingle unpaid time with paid time.
Depending upon the reason for leave and your eligibility for specific leave entitlements, you may be allowed
to use sick leave accruals for leave associated with bonding with a newborn child or newly placed adoptive
child and for caregiver leave. Your Human Resources Office will notify you if you meet the criteria for use
of sick leave accruals for these reasons.
This form provided by the Department of Administrative Services
3
Fill In Chart: You must designate the number of days, or hours, or you may indicate “ALL available.”
Sick Leave
Vacation
Personal
Comp Time Sick Family
Parental
USE OF
Accruals
Accruals
Leave
Days (based
Days (based
on bargaining
on bargaining
ACCRUALS
unit contract)
unit contract)
Days/Hours
Days/Hours Days/Hours Days/Hours Days/Hours
Days/Hours
PERSONAL MEDICAL LEAVE
My own illness or
Not Applicable
Not Applicable
injury
Disability period related
Not Applicable
Not Applicable
to my pregnancy &
childbirth
Organ donor
Not Applicable
Not Applicable
(other
than the paid leave
entitlement of 15 days)
Bone marrow
Not Applicable
Not Applicable
(other than the
donor
paid leave entitlement
of 7 days)
CAREGIVER LEAVE
Spouse
Not Applicable
(including
providing care to your wife
during the disability period
associated pregnancy and
childbirth)
Not Applicable
Parent
Parent-in-law
Not Applicable
Not Applicable
Child
Not Applicable
BONDING LEAVE
Birth of child
Not Applicable
Adoption of child
Not Applicable
Placement of foster
Not Applicable
Not Applicable
child
This form provided by the Department of Administrative Services
4
Sick Leave
Vacation
Personal
Comp Time
Sick Family
Parental
USE OF
Accruals
Accruals
Leave
Days (based
Days (based
on bargaining
on
ACCRUALS
unit contract)
bargaining
unit contract)
REASON
Days/Hours
Days/Hours Days/Hours
Days/Hours
Days/Hours
Days/Hours
MILITARY FAMILY LEAVE
Military Caregiver -
Not
Applicable
Covered Servicemember
Military Caregiver -
Not
Applicable
Covered Veteran
Qualifying Exigency
Not Applicable
Not
Applicable
leave
____________________________________________________
_______________
(Employee Signature)
(Date)
Return the completed form(s) to your agency Human Resources Office.
This form provided by the Department of Administrative Services
Page of 4