3.660 RCUH Family Leave (relating FFCRA)
RCUH Expanded Family Medical Leave Request Form
(Form B-11EFML)
(FFCRA Leave - Care for Self or Family Member)
(Effective from April 1, 2020 through December 31, 2020 for Working Employees)
INSTRUCTIONS: Please complete this form and submit with the RCUH Form D-48EPSL and supporting documents (if applicable)
via encrypted email or by fax (808) 956-5022 (RCUH Employee Benefits fax number). NOTE: If approved your Expanded Family
Medical Leave runs concurrently with your 12-week FMLA benefit entitlement (if applicable).
Section I: Employee/Project Contact Information: Please fill out all blanks requested below:
Employee Name:
Section II: Leave Request Information: The Expanded Family Medical Leave benefit is only available
between April 1, 2020 through December 31, 2020.
A. Please select if leave is Continuous Intermittent (Requires PI Approval)
B. Start Date of Leave:
Expected Return to Work Date:
C. Please select the applicable box(es) below indicating the reason for your Family Leave
request.
1. Own Serious Health Condition or Quarantine or Isolation Order (Attach RCUH Form D-48EPSL. May be required
to complete a WH-380E form.)
2. Serious Health Condition of a Family Member: For My Child, Spouse/Reciprocal Beneficiary/Civil Union
Partner, Sibling or Parent (includes parents-in-law, grandparents, and grandparents-in-law). Attach RCUH Form
D-48EPSL. May be required to complete a WH-380F form.
3. Caring for child: Child’s school or place of care is closed (or child care provider is unavailable) due to
COVID-19 related reasons
. Attach RCUH Form D-48EPSL.
4. Other Circumstance: Experiencing any other substantially-similar condition
specified by the U. S. Dept. of Health & Human Services.
Specify:_________________________________________________________
Section III: Employee Certification: I certify that the information provided on this document and other related
document is accurate. I acknowledge any falsification of information could result in my termination of employment.
A. Print Name & Signature:
Date:
Section IV: Principal Investigator Acknowledgement/Approval: I acknowledge this is consider a protected
leave. (Check box if you approve the employee taking intermittent leave as noted above)
A. PI/Supervisor’s Print Name & Signature:
Date:
Please return this form via email to RCUH Benefits at rcuh_benefits@rcuh.com or via fax at (808) 956-5022 at least ten
(10) working days before the requested start date of leave or as soon as possible (if leave is not foreseeable). RCUH
Benefits will provide you a determination of your eligibility within five (5) business days of receipt of your EFML Form.
RCUH Form B-11EFML
Created 04/01/2020, rev. 04/02/2020
of the University of Hawai‘i
Human Resources Department
click to sign
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