Research Corporation of the University of Hawaiʻi

RCUH Victims Leave Form (B-21)
Submit via email: [email protected] or Fax: 956-5022
I. EMPLOYEE INFORMATION
Last Name:
First Name:
Email:II. LEAVE REQUEST INFORMATION
A. Check One:
I am a victim of domestic or sexual violence
My minor child is a victim of domestic or sexual violence
List Name and Age of Minor Child:
B. I am taking Victims Leave for the following reason (check one):
1. To seek medical attention for the employee or employee’s minor child to recover from physical or psychological injury or disability caused by domsetic or sexual violence.
2. Obtain services from a victim services organization.
3. Obtain psychological or other counseling.
4. Temporarily or permanently relocate.
5. Take legal action, including preparing for participating in any civil or criminal legal proceeding related to or resulting from the domestic or sexual violence, or other actions to enhance the physical, psychological, or economic health or safety of the employee or the employee’s minor child or to enhance the safety of those who associate with or work with the employee.
C. Leave Period:
First Day of Leave:
Expected Return Date;

 

III. DOCUMENTS REQUIRED
A. If the leave is needed to seek medical attention to recover from physical or psychological injury or disability (Type 1. or 3. as noted in section II.B. above), you must complete this form and provide:
1. A certificate from a health care provider estimating the number of leave days necessary and the estimated commencement and termination date of leave required by the employee; and
2. Prior to the employee’s return, a medical certificate from the employee’s attending health care provider attesting to the employee’s condition and approving the employee’s return to work.
B. If your Victims Leave will total five (5) or less calendar days in the current calendar year, and the leave is for non-medical reasons (Type 2., 4. or 5. as noted in section II.B. above), you must complete this form and no other documentation is required.
C. If your Victims Leave will total more than five (5) calendar days in the current calendar year, and the leave is for non-medical reasons (Type 2., 4. or 5. as noted in section II.B. above), you must provide one of the following:
1. A signed written statement from an employee, agent, or volunteer of a victim services organization, from the your (or your minor child’s) attorney, advocate, or a medical or other professional from whom you (or your minor child) has sought assistance related to the domestic or sexual violence; or
2. A police or court record related to the domestic or sexual violence.

IV. ACKNOWLEDGEMENT & CERTIFICATION
I certify that I have read the 3.650 RCUH Victims Protections/Leave policy and I qualify for this leave under the policy and Chapter 378 of the Hawaii Revised Statutes. I certify the accuracy of this form and any attached documents (if applicable) and understand that falsification of records may lead to termination of my employment.
Employee Signature
Date
Submit to RCUH Human Resources via scan/email at [email protected] or fax at 956-5022.
RCUH Form B-21
Created 04/11/2012, (Revised 06/01/2012, 06/09/2014, 10/03/2017, 2/27/2018)