Family Leave Guidelines For Employees Of The University Of Hawaii Page 4
Download a blank fillable Family Leave Guidelines For Employees Of The University Of Hawaii in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Family Leave Guidelines For Employees Of The University Of Hawaii with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4APPLICATION FOR FAMILY LEAVE
Clear Form
(To be retained by the division)
Employee Name:
_______________________________________________________________________
Position Title:
_______________________________________________________________________
Bargaining Unit:
_______________________________________________________________________
Division/Branch/Unit: _______________________________________________________________________
1.
Specify the reason for the family leave:
Birth of an employee’s child
Adoption of a child by an employee
Care of an employee’s child, spouse, or parent with a serious health condition
2.
If family leave is being taken to care for your child, spouse or parent with a serious health condition,
please provide the following information:
A. Family relationship to the person being cared for:
_______________________________________________________________________________
B. The serious health condition must be an acute, traumatic, or life-threatening illness, injury, or
impairment and which involves treatment or supervision by a health care provider. List name of health
care provider. (If not known at this time, indicate “not known” and name of health care provider may
be submitted at a later date.)
_______________________________________________________________________________
C. Probable duration of the serious health condition if known:
_______________________________________________________________________________
3.
Period of leave (dates) and total number of working hours being utilized for family leave:
__________________________________________________________________________________
The information contained in this form may be subject to verification by the employer.
I certify that the above information is true and accurate.
_________________________________________________________
________________________
Employee Signature
Date
UH FORM 46 (PERS) 4/92
ADVERTISEMENT
0 votes
Related Articles
Related forms
Applied Behavioranalysis - Application For Licensure/certification - The University Of The State Of New York The State Education Department - 2016
Legal
Occupational Therapy/occupational Therapy Assistant - Application For Licensure/authorization - The University Of The State Of New York The State Education Department - 2016
Legal
Cytotechnologist/certified Histological Technician - Application For Limited Permit - The University Of The State Of New York The State Education Department - 2009
Legal
Release And Indemnification Agreement For Minors Template - The University Of Texas At Arlington
Business
Form 5306-a - Application For Approval Of Prototype Simplified Employee Pension (sep) Or Savings Incentive Match Plan For Employees Of Small Employers (simple Ira Plan)
Financial
Form 5306-a - Application For Approval Of Prototype Simplified Employee Pension (sep) Or Savings Incentive Match Plan For Employees Of Small Employers (simple Ira Plan)
Financial
Related Categories
Parent category: Business