RCUH Policies and Procedures
of the University of Hawai‘i
Human Resources Department
FAMILY LEAVE APPLICATION FORM
IMPORTANT NOTICE: If leave is foreseeable, prior to submitting this form to RCUH, you must notify your Principal Investigator or Supervisors regarding your utilization of family leave.
Part I: Employee/Project Contact Information: Please fill out all blanks requested below
Part II: Leave Request Information: Please notate start date and return to work date.
Please select the applicable box(es) below indicating the reason for your Family Leave request.
Start Date of Leave: / / Return to Work Date: / /
Birth of a Child/Care for Newborn (select from the following options):
Expected Mother – For Birth/Recovery and to Care for Newborn After Birth Expected Mother – Care for Newborn After Birth ONLY
Father of a Newborn – Care for Spouse and to Care for Newborn After Birth Father of a Newborn – Care for Newborn After Birth ONLY
Serious Health Condition (select from the following options):
For My Own Serious Health Condition (non work-related)
For My Child, Spouse/Reciprocal Beneficiary/Civil Union Partner, or Parent (includes
parents-in-law, grandparents, and grandparents-in-law)
Adoption of Child
Placement of My Child into Foster Care
Military Caregiver Leave
Care for a Covered Service member (spouse, child, parent or next of kin) with a Serious Injury or Illness
Qualifying Exigency for Military Dependent (arising out of the foreign deployment of the employee’s spouse, son, daughter, or parent)
Employee Name: RCUH Employee ID#:
Daytime Phone #: Email:
PI Name: Email:
Supervisor Name: Email:
Time Keeper Name: Email:
Part III: Employee Certification:
Employee’s Signature: Date:
Part IV: Principal Investigator/Supervisor Acknowledgement:
Principal Investigator/Supervisor’s Signature:
Please return this form via email to RCUH Benefits at firstname.lastname@example.org or via fax at (808) 956-5022 at least thirty (30) days before the requested start date of leave (if leave is foreseeable) or as soon as possible (if leave is not foreseeable). RCUH Benefits will contact you within five (5) business days of receipt of your Family Leave Request Form to provide you with our determination on your eligibility status for Family Leave.
RCUH Form B-11 Created 04/06/2015 Rev 05/03/2016