University of Connecticut University of UC Title Fallback Connecticut

Leave Request: Maternity – Birth of a Child

Please read carefully the information outlined below regarding your family/medical leave entitlements under federal (FMLA) and state (C.G.S. 5-248a) law and then complete and submit this form. Be sure to attach or provide any additional required documentation requested.

Under federal FMLA, employees are entitled to take up to 12 weeks of unpaid leave in a 12-month period provided they meet eligibility and reason for leave requirements. Additionally, permanent state employees have an entitlement of up to 24-weeks of unpaid family medical leave in a two-year period. You may be eligible for leave under one or the other law, under both or none. Depending upon several factors, if you are eligible under both and the reason for leave qualifies under both laws, the leave may count simultaneously toward both
entitlements.

Military Family Leave: Federal: Eligible employees who are family members of covered service members (including covered veterans) will be able to take up to 26 workweeks of unpaid federal FMLA leave in a “single 12-month period” to care for a covered service member or a covered veteran with a covered serious illness or injury incurred or aggravated in the line of duty on covered active duty and/or up to 12 workweeks of unpaid federal FMLA leave because of any qualifying exigency arising out of the fact that employee’s spouse, son, daughter, or parent is a covered service member on covered active duty. State: Eligible employees will be able to take up to 26 weeks of unpaid leave in a two-year period to care for an immediate family member or next of kin who is a current member of the US Armed Forces, National Guard or military reserves and is undergoing medical treatment, recuperation or therapy, an inpatient, or on the temporary disability retired
list for a serious illness or injury. Under both state and federal law, an employee can take caregiver leave only one time per covered service member, per injury.

Note: A leave request based on an employee’s serious health condition or the serious health condition of an employee’s spouse, child or parent must be accompanied by a verifying medical certification from a licensed physician or other “healthcare provider.”
(Form P-33A—Employee or Form P-33B—Caregiver)

Note:A leave request for “military family leave” must be accompanied by a certification (Form DOL-WH384 – Certification of Qualifying Exigency; Form DOL-WH385 Certification for Serious Injury or Illness of Current Service member; or Form DOL-WH385-V Certification for Serious Injury or Illness of a Veteran).