Connecticut Employee Application for FMLA

State:
Multi-State
Control #:
US-AHI-200
Format:
Word
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Description

This form is an application for Family and Medical Leave. It is to be filled out by an employee who is requesting a leave of absence.

Connecticut Employee Application for FMLA is a formal document used by employees in the state of Connecticut to apply for leave under the Family and Medical Leave Act (FMLA). This application is designed to ensure that eligible employees who need time off for specific family and medical reasons are granted protected leave without any negative consequences of their employer. The Connecticut Employee Application for FMLA is an essential tool that allows employees to request leave for a variety of FMLA qualifying reasons, including: 1. Birth and care of a newborn child: Employees can use this application to take FMLA leaves to bond with and care for a newborn child within the first year after birth. 2. Placement and care of an adopted or foster child: If an employee is adopting or fostering a child, they can apply for FMLA leave using this application to provide care and bond with the newly placed child. 3. Serious health condition: Employees suffering from a serious health condition can request FMLA leave using this application. This includes conditions that require inpatient care, continuing treatment by a healthcare provider, or chronic illnesses that cause periodic absences. 4. Care for an immediate family member with a serious health condition: When an employee's immediate family member (spouse, child, or parent) is facing a serious health condition, they can apply for FMLA leave through this application to provide necessary care and support. 5. Qualifying exigency: In case an employee's spouse, child, or parent is a military member on covered active duty or is called to covered active duty status, they may be eligible for FMLA leave to address qualifying exigencies, such as attending certain military events or making childcare arrangements. The Connecticut Employee Application for FMLA requires employees to provide relevant information, including their name, contact details, employee identification, work unit, supervisor details, the leave requested (start and end dates), purpose of leave, and necessary medical documentation where applicable. Employees should also provide any supporting documentation or details that substantiate their need for FMLA leave. It is important to note that there may be variations in the specific format or additional requirements for the Connecticut Employee Application for FMLA across organizations and industries. Employees are advised to consult their employer's FMLA policy or Human Resources department for the exact application form and any additional guidelines.

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FAQ

The FMLA guarantees up to 12 weeks of unpaid leave but only applies to companies with 50 or more employees. Constitution state workers can submit applications for paid leave benefits starting this fall and winter.

In order to be eligible to take leave under the FMLA, an employee must (1) work for a covered employer, (2) work 1,250 hours during the 12 months prior to the start of leave, (3) work at a location where 50 or more employees work at that location or within 75 miles of it, and (4) have worked for the employer for 12

The state of Connecticut FMLA allows up to 16 weeks of unpaid leave in a 24-month period (or up to 24 weeks if you are a state of Connecticut employee). Pregnancy: The Connecticut FMLA allows up to 12 weeks of unpaid leave in a 12-month period.

Doctors aren't the only health care providers who may certify FMLA leave. Podiatrists, dentists, clinical psychologists, optometrists and chiropractors can all certify leave, as can nurse practitioners, nurse-midwives, clinical social workers and physician assistants.

Care for a family member with a serious health condition; Because of an employee's own serious health condition; To serve as an organ or bone marrow donor; To address qualifying exigencies arising from a spouse, son, daughter or parent's active-duty service in the armed forces; and.

You can apply online or call the toll-free application line at (877) 499-8606. To apply online, create an account with CT Paid Leave. Get started with this step-by-step instructional video. If you know when you will be taking leave, submit your application no more than 30 days before the leave start date.

According to the CT Paid Leave Authority, those eligible to receive family leave benefits must be currently employed in Connecticut, have worked in Connecticut in the past 12 weeks but are currently unemployed or are a sole proprietor or self-employed person and resident of Connecticut.

EligibilityHave worked for your employer for at least 12 months; and.Have worked for your employer for at least 1,250 hours in the 12 months before you are taking leave; and.Work at a location where your employer has at least 50 employees within 75 miles of your worksite.

How to File a Paid Family Leave (PFL) Claim by MailVisit Online Forms and Publications and order a form online. A form will be mailed to you.Obtain the form from your physician/practitioner or employer.Visit an SDI Office.Call 1-877-238-4373. California Relay Service (711) Provide the PFL number (1-877-238-4373)

To apply for FMLA, the employee must take an FMLA Medical Certification Form to their health care provider. This form ensures that the employee's or family member's applicable health condition is valid. After receiving the form, the employee must return it within 15 calendar days.

More info

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Connecticut Employee Application for FMLA