Family Leave Request Form printable pdf download

3.660 RCUH Family Leave

RESEARCH CORPORATION OF THE UNIVERSITY OF HAWAII

FAMILY LEAVE REQUEST FORM

Part I:

Employee Contact Information

Name of Employee:

Date:

Daytime Phone #:

Email:

Supervisor:

Email:

Part II:

Leave Request Information

Start Date of Leave:

Check here if this is an estimated date

Return to Work Date:

Check here if this is an estimated date

Check here if Intermittent Leave is needed

(If start/return dates above change, please notify supervisor and RCUH HR at )

Please check off one (1) of the boxes below indicating the type of leave requested (submit additional

documentation as noted below if available). Email completed form to .

A. Birth of a child/Care for newborn



Birth of a child – Certification of Health Care Provider for Employee’s Serious Health Condition (Form

WH-380-E);



Care for newborn – Certification of Health Care Provider for Employee’s Serious Health Condition

(Form WH-380-E OR Form WH-380-F) and Birth Certificate issued by the Health Care Provider,

Department of Health, or family court.

B. Adoption of child



Certification showing placement of the child with the employee issued by a recognized adoption

agency, the attorney handling the adoption, or by the individual officially designated by the birth

parent to select and approve the adoptive family.

C. Placement of employee’s child into foster care



Certification showing placement of the child into foster care issued by a recognized foster

care/adoption agency, the attorney handing the adoption/foster care placement, of by the individual

officially designated by the employee to select and approve the foster care/adoptive family.

D. Care of child, spouse/civil union partner, or parent with a serious health condition

Name:

____________________ Relationship:

__________________



Certification of Health Care Provider Form for Family Member (Form WH-380-F).

E. Serious health condition of the employee (non work-related)



Certification of Health Care Provider for Employee’s Serious Health Condition (Form WH-380-E).

F. Care for spouse, child, parent or next of kin who is a covered servicemember

Name:

____________________ Relationship:

__________________



Certification for Serious Injury or Illness of Covered Servicemember for Military Family Leave (Form

WH-385).

G. Qualifying exigency (spouse, son, daughter, or parent)

Name:

____________________ Relationship:

__________________



Certification of Qualifying Exigency for Military Family Leave (Form WH-384) and copy of Military

Member’s Active Duty Orders.

H. Is your spouse also an RCUH employee? If yes, provide name:

_______________

Part III:

Certification

Employee’s Signature: ________________________________ Date: ______________________

RCUH Form B-11

Created 05/21/2004, (Revised 03/13/2008, 01/01/2012, 10/26/2013, 02/03/2014, 07/23/2014)

Family Leave Request Form

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