Transcription of Family Medical Leave and/or Dependent Care Leave …
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Family Medical Leave and/or Dependent Care Leave …
Family Medical Leave and/or Dependent care Leave Request Form CONNECTICUT ONLY Date:_____ _____ _ To:_____ _____ _____ (Supervisor s Name) (Department) _____ From: _____ _____ (Employee s Name) (Employee Badge/ID Number) I hereby request: Paid Dependent care Leave of Absence for _____ days, from _____ through _____. Family Medical Leave of Absence for days, from _____ through _____. Reason for Leave : Check One: Check One: FMLA Paid Dependent care Personal serious illness NA (Complete Certification of health care Provider WH-380-E) serious illness of your: Child Spouse Parent serious illness or injury of: Military Service member (Complete Certification of health care Provider WH-385) Qualifying Exigencies for Military Leave (Complete Qualifyi)
4. For all employees who request a leave due to a personal serious illness (not associated with a disability claim), a birth of a child or the need to care for a seriously ill child, spouse, parent, qualifying exigencies or illness/injury of a service member, I must complete the “Certification of Health Care Provider” form (see above for proper form) within 15 calendar days of receiving ...
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