Search Human Resources Business Rules and Regulations

FMLA Forms

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

    Form to be completed by agency human resources department notifying employee the disposition of the employee's request for leave of absence under the Federal Family and Medical Leave Act (FMLA) and/or State Family/Medical Leave (C.G.S 5-248a)

  • 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 leave of absence under the Federal Family and Medical Leave Act (FMLA) and/or State Family/Medical Leave (C.G.S 5-248a)

  • 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/serious illness"; form must be completed by family member's attending physician or practitioner

  • FMLA - Core-CT Coding Form - FMLA-HR-2c

    Form to be completed by agency human resources when the employee has been approved for federal FMLA and/or state C.G.S.5-248a leave entitlement and is attached to the employee’s HR2b – Designation Notice. This form can also be used when a workers’ compensation absence is counted against the employee’s federal FMLA entitlement.

  • 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 physician or practitioner

  • FMLA Employee Request Form - FMLA-HR-1

    Form to be completed by employee requesting leave of absence under the Federal Family and Medical Leave Act (FMLA) and/or State Family/Medical Leave (C.G.S. 5-248a)

  • 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 leave under federal FMLA and/or C.G.S. 5-248a