FAMILY AND MEDICAL LEAVE REQUEST FORM

State of Connecticut

Federal Authority: 29 U.S.C. §§ 2601 et seq.; 29 C.F.R. Part 825
State Authority: CT FMLA (Conn. Gen. Stat. §§ 31-51kk–31-51qq); CT PFML (Conn. Gen. Stat. §§ 31-49e–31-49t)

TABLE OF CONTENTS

1. Employee Information
2. Employer Information
3. Type of Leave Requested
4. Federal FMLA Overview
5. Connecticut FMLA and PFML Provisions
6. Leave Schedule and Dates
7. Intermittent or Reduced Schedule Leave
8. Medical Certification
9. Job Restoration Rights
10. Benefits Continuation
11. Connecticut-Specific Notes
12. Employee Acknowledgment and Signature
13. Employer Response

1. EMPLOYEE INFORMATION

2. EMPLOYER INFORMATION

3. TYPE OF LEAVE REQUESTED

Please indicate the reason for your leave request:

☐ Own Serious Health Condition — A serious health condition that renders the employee unable to perform essential job functions (29 U.S.C. § 2612(a)(1)(D); Conn. Gen. Stat. § 31-51ll)

☐ Family Member Care — To care for a family member with a serious health condition (29 U.S.C. § 2612(a)(1)(C); Conn. Gen. Stat. § 31-51ll)
- Relationship to employee: [________________________________]
- Name of family member: [________________________________]

☐ Birth and Bonding — For the birth of a child and to bond with the newborn (29 U.S.C. § 2612(a)(1)(A); Conn. Gen. Stat. § 31-51ll)

☐ Adoption or Foster Care Placement — For placement of a child for adoption or foster care (29 U.S.C. § 2612(a)(1)(B); Conn. Gen. Stat. § 31-51ll)

☐ Qualifying Exigency — For a qualifying exigency related to a family member's military service (29 U.S.C. § 2612(a)(1)(E))
- Type of exigency: [________________________________]

☐ Military Caregiver Leave — To care for a covered servicemember with a serious injury or illness (29 U.S.C. § 2612(a)(3))
- Relationship to servicemember: [________________________________]

☐ Organ or Bone Marrow Donation — CT FMLA qualifying reason (Conn. Gen. Stat. § 31-51ll)

☐ Domestic Violence / Stalking — For needs arising from being a victim of family violence (Conn. Gen. Stat. § 31-51ss)

4. FEDERAL FMLA OVERVIEW

• Eligibility: 12 months of employment, 1,250 hours in prior 12 months, worksite with 50+ employees within 75 miles (29 C.F.R. § 825.110).
• Leave Entitlement: Up to 12 workweeks of unpaid, job-protected leave per 12-month period.
• Military Caregiver Leave: Up to 26 workweeks in a single 12-month period.
• Notice: 30 days' advance notice when foreseeable; as soon as practicable otherwise.

5. CONNECTICUT FMLA AND PFML PROVISIONS

5A. Connecticut Family and Medical Leave Act (CT FMLA)

Employer Coverage: All private employers with 1 or more employees in Connecticut.

Employee Eligibility: Employed for at least 3 months (no hours-of-service threshold).

Leave Entitlement:
- Up to 12 weeks of job-protected leave in a 12-month period.
- Additional 2 weeks available for a serious health condition resulting in incapacitation during pregnancy (up to 14 weeks total).

Expanded Family Member Definition (CT FMLA):
CT FMLA covers a broader set of family relationships than federal FMLA:
- Spouse or domestic partner
- Child (minor or adult)
- Parent, parent-in-law
- Sibling
- Grandparent, grandchild
- Any individual related by blood or affinity whose close association is the equivalent of a family relationship

5B. Connecticut Paid Family and Medical Leave (CT PFML)

Eligibility: Employee must have earned at least $2,325 in the highest quarter of the base period.

Benefit Duration: Up to 12 weeks of paid leave per 12-month benefit period (plus 2 additional weeks for pregnancy-related incapacitation).

Wage Replacement (2026):
- 95% of average weekly wage up to the state minimum wage threshold ($16.94/hr as of January 1, 2026 x 40 hrs).
- 60% of wages above that threshold.
- Maximum Weekly Benefit (2026): $1,016.40/week (60x the minimum wage).

Employee Contribution (2026):
- 0.5% of wages, up to the Social Security wage cap ($184,500 in 2026).
- Maximum annual contribution: approximately $922.50.

☐ Employee is requesting CT PFML paid benefits in addition to CT FMLA/federal FMLA job protection.
☐ Employee is requesting job-protected leave only (no CT PFML claim).

CT Paid Leave Claim Number (if filed): [________________________________]

6. LEAVE SCHEDULE AND DATES

Employer's 12-Month Leave Period Method (FMLA): [________________________________]

Federal FMLA Leave Already Used: [____] weeks [____] days

Federal FMLA Leave Remaining: [____] weeks [____] days

CT FMLA Leave Already Used: [____] weeks [____] days

CT FMLA Leave Remaining: [____] weeks [____] days

CT PFML Leave Already Used: [____] weeks [____] days

CT PFML Leave Remaining: [____] weeks [____] days

7. INTERMITTENT OR REDUCED SCHEDULE LEAVE

☐ I am not requesting intermittent or reduced schedule leave.

☐ I am requesting intermittent or reduced schedule leave.

If intermittent or reduced schedule leave is requested:

8. MEDICAL CERTIFICATION

☐ Medical certification is attached (DOL Form: [________________________________])

☐ Medical certification will be provided by: [__/__/____]

☐ Medical certification is not required for this leave type

Certification Form Required:
- ☐ WH-380-E — Employee's Serious Health Condition
- ☐ WH-380-F — Family Member's Serious Health Condition
- ☐ WH-384 — Qualifying Exigency for Military Family Leave
- ☐ WH-385 — Serious Injury or Illness of a Current Servicemember
- ☐ WH-385-V — Serious Injury or Illness of a Veteran
- ☐ CT Paid Leave Authority certification (for PFML claims)

9. JOB RESTORATION RIGHTS

• Federal FMLA: Restoration to the same or equivalent position (29 U.S.C. § 2614(a)).
• CT FMLA: The employee is entitled to return to the same position or, if not available, an equivalent position with equivalent pay, benefits, and conditions (Conn. Gen. Stat. § 31-51nn).
• Anti-Retaliation: Both federal FMLA and CT FMLA prohibit retaliation for requesting or taking leave.

☐ Employee is designated as a "key employee" under 29 U.S.C. § 2614(b).

10. BENEFITS CONTINUATION

• Federal FMLA: Employer must maintain group health insurance during leave (29 U.S.C. § 2614(c)).
• CT FMLA: Employer must continue all employment benefits during the leave period (Conn. Gen. Stat. § 31-51oo).
• Employee must continue to pay their share of premiums.

11. CONNECTICUT-SPECIFIC NOTES

• Concurrent Leave: Federal FMLA, CT FMLA, and CT PFML run concurrently when all three apply.
• CT PFML Claims: File claims through the CT Paid Leave Authority at ctpaidleave.org.
• Private Plan Option: Employers may use an approved private plan in lieu of the state CT PFML program if it meets or exceeds state benefits.
• Small Employer Coverage: CT FMLA applies to employers with as few as 1 employee — significantly broader than the federal 50-employee threshold.
• Organ/Bone Marrow Donation: CT FMLA uniquely covers leave for organ or bone marrow donation as a qualifying reason.
• No PTO Substitution Required: Employers cannot require employees to exhaust accrued PTO before accessing CT PFML.

☐ Employer participates in the state CT PFML program.
☐ Employer has an approved private PFML plan.

12. EMPLOYEE ACKNOWLEDGMENT AND SIGNATURE

By signing below, I certify that:

1. The information provided is true and complete to the best of my knowledge.
2. I understand my rights under federal FMLA, CT FMLA, and CT PFML.
3. I understand that medical certification may be required.
4. I understand that misrepresentation may result in disciplinary action and/or denial of benefits.

13. EMPLOYER RESPONSE

☐ APPROVED — Leave is designated as FMLA/CT FMLA/CT PFML qualifying.
☐ PENDING — Additional information or certification required.
☐ DENIED — Leave is not qualifying. Reason: [________________________________]

Notices Provided:
- ☐ WH-381 (Eligibility/Rights & Responsibilities Notice) — Date: [__/__/____]
- ☐ WH-382 (Designation Notice) — Date: [__/__/____]
- ☐ CT PFML Rights Notice — Date: [__/__/____]

This form does not replace DOL FMLA forms or CT Paid Leave Authority claim forms. Employers must issue all required federal and state notices.

Sources and References:
- U.S. Department of Labor — FMLA
- Conn. Gen. Stat. §§ 31-51kk–31-51qq (CT FMLA)
- Conn. Gen. Stat. §§ 31-49e–31-49t (CT PFML)
- CT Paid Leave Authority
- CT Department of Labor — FMLA FAQs