Non-Certified Staff Initial Request for FMLA

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Please use your Hamden.org email and fill out this form to submit your request for FMLA. Per Federal and State FMLA, paperwork will be provided within 5 days of request.

Federal and CT FMLA is job-protected unpaid leave up to 60 days in a one-year period. The BOE defines a one-year period as a fiscal year beginning July 1 and ending June 30. Federal and CT FMLA will run concurrently (at the same time) if eligible for both.

Email *

Requestor's First and Last Name: *

Requestor's Specific Position (ie: Paraprofessional/ELP Teacher/Tutor/etc) *

Requestor's Building/School: *

Today's Date: *

YYYY

Select if applying for Self *

Birth of a child, or placement of a child with you for adoption or foster care, and to bond with the newborn or newly-placed child (Federal & State FMLA)

Your own serious health condition (Federal & State FMLA)

Organ Donation (State FMLA Only)

Bone Marrow Donation (State FMLA Only)

Not Applicable

Select if applying for Qualified Family Member (select one) *

Parent (Federal & State FMLA)

Child under age 18 (Federal FMLA)

Child 18 years or older and incapable of self-care because of a mental or physical disability (Federal FMLA)

Child (of any age) (State FMLA only)

Spouse (Federal & State FMLA)

Grandchild (State FMLA only)

Spouse's Parent (State FMLA only)

Grandparent or Spouse's Grandparent (State FMLA only)

Sibling or Spouse's Sibling (State FMLA only)

Person related by blood or affinity whose close association with you is equivalent to one of the above-listed relationships (State FMLA only)

Not Applicable

Select if applying for Military Family Leave *

Qualifying Exigency arising out of the covered active duty of my spouse, parent, or child (Federal & State FMLA)

Military caregiver leave for my spouse, parent, child, or next of kin who is a covered service member (Federal & State FMLA)

Military caregiver leave for my spouse, parent, child or next of kin who is a covered veteran (Federal & State FMLA)

Not Applicable

Type of leave you are requesting (Select one) *

Consecutive (blocks of time with a documented start/anticipated end date)

Intermittent (periodic/occasional absences related to your approved FMLA request

Anticipated Start Date of your FMLA Leave *

YYYY

A copy of your responses will be emailed to the address you provided.

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