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RESEARCH CORPORATION OF THE UNIVERSITY OF HAWAII (Research Corporation of University of Hawaii)

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3.660 RCUH Family Leave
RCUH Form B-11
Created 04/06/2015
RESEARCH CORPORATION OF THE UNIVERSITY OF HAWAII
FAMILY LEAVE REQUEST FORM
Part I: Employee/Project Contact Information: Please fill out all blanks requested below
Employee Name:
RCUH Employee ID#:
Daytime Phone #:
Email:
PI Name:
Email:
Supervisor Name:
Email:
Time Keeper Name:
Email:
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 Servicemember (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)
Part III: Employee Certification:
Employee’s 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 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.
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RESEARCH CORPORATION OF THE UNIVERSITY OF HAWAII (Research Corporation of University of Hawaii)

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Completed 29 July 2020

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