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 rcuh_benefits@rcuh.com)
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 rcuh_benefits@rcuh.com.
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 – 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: ______________________
