Medical Leave/FMLA

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• DAS General Letter 39 - Family Medical Leave

  Statewide policy for family and medical leave to ensure consistent application and implementation of the state and federal family and medical leave laws.

• Donation of Leave Time for Certain Non-Represented Employees (E-Item 9023)

  Donation of Leave Time for Employees Assigned to the EX Compensation Plan or Gubernatorial Appointees Assigned to the MP Compensation Plan.

• Family and Medical Leave Entitlements Manual

  The official Family and Medical Leave Entitlements Manual for state HR professionals

• FMLA - Core-CT Coding Form - FMLA-HR2c

  Form to be completed by agency human resources when the employee has been approved for family leave, medical leave or military family leave and is attached to the employee's HR2b - Designation Notice.

• FMLA - Employee's Intent to Return to Work Form - FMLA-HR-3

  Form to be completed by the employee indicating his/her intent to return to work prior to taking family leave, medical leave or military family leave.

• FMLA - Extension of 2017 SEBAC Item No. 2495-E

  Extension of the Family and Medical Leave language of the SEBAC Agreement to Employees Exempt from Collective Bargaining

• FMLA - Military Exigency for Family Form - WH-384

  Form to be completed by agency and then employee seeking FMLA leave due to a qualifying exigency due to a military member’s covered active duty or call to covered active duty status

• FMLA - Military Family Leave - Med Certificate for Military Family Member - WH-385

  Form to be completed by an agency, employee and then health care provider when an employee requests leave under the FMLA to care for a family member who is a current member of the Regular Armed Forces, the National Guard, or the Reserves who is undergoing medical treatment, recuperation, or therapy, is otherwise in outpatient status, or is otherwise on the temporary disability retired list for a serious injury or illness.

• FMLA - Military Family Leave - Med Certificate for Veteran Family Member - WH-385V

  Form to be completed by an employee and then health care provider when the employee seeks military caregiver leave under the FMLA leave due to a serious injury or illness of a covered veteran; this certification must provide sufficient facts to support the request for leave.

• FMLA Agency Response Designation Notice - FMLA-HR-2b

  Form to be completed by agency human resources department notifying employee of the disposition of the employee's request for family leave, medical leave or military family leave.

• FMLA Agency Response Eligibility Notice to Employee - FMLA-HR-2a

  Form to be completed by agency human resources department notifying employee of his/her eligibility in response to employee's request for family leave, medical leave or military family leave.

• FMLA Caregiver Medical Certificate P-33B

  Form to be used by employees seeking family leave to care for a spouse, child, or parent with a “serious health condition". Form must be completed by family member's attending medical provider.

• FMLA Employee Medical Certificate P-33A

  Form to be used by employee who is absent for personal illness, including FMLA absences; form must be completed by employee's attending medical provider.

• FMLA Employee Request Form - FMLA-HR-1

  Form to be completed by employee requesting family leave, medical leave or military family leave.

• FMLA Statement of Qualifying Family Relationship FMLA-HR4

  For Family Leave or Military Family Leave