Connecticut workers can use CT Paid Leave to care for a spouse, parent, child or next of kin who is a current service member with a serious injury or illness. The service member's health care provider completes this three-page certification (CTPL-0010), covering line-of-duty status, the care needed, the DoD casualty classification and the amount of leave.
The applicant completes their own, the relationship and the service member's details. The service member's provider, whether DoD, VA, TRICARE network or non-network, or another provider under 29 CFR 825.125, completes the medical information and signs with credentials.
Download the current version from the source each time; forms change without notice.
Certification for Serious Injury or Illness of a Current Service Member for Military Caregiver Leave
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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Yes. The application document checklist accepts fully completed FMLA medical documentation on Form WH-385 in place of the CT certification, uploaded as a Caregiver Certification Form. A copy of an Invitational Travel Authorization or Invitational Travel Order is also accepted, uploaded as Military Orders.
CT Paid Leave benefits are limited to 12 weeks in a 12-month period, even though federal and Connecticut FMLA provide up to 26 weeks of job-protected leave for military caregivers. The leave is for a spouse, parent, child or next of kin of the service member.
The form tells the employee they may still qualify for leave to care for a family member with a serious health condition under the FMLA definition in 29 CFR 825.113. In that case they may be asked to complete the federal WH-380-F or an employer form seeking the same information.