This form is to be used when an employee is requesting leave for COVID or non-COVID related reasons such as taking time off work to recover from surgery, taking care of family due to their serious health condition, birth/placement of a child, or certain qualifying military leaves of absence. Submitting an Initial Leave Request Form is the first step in the process to determine if the employee meets the requirements of the Family and Medical Leave Act of 1993 as amended; Chapter 49.78, FAMILY LEAVE of Title 49 RCW: Labor Relations, Chapter 296-134 WAC-FAMILY LEAVE; Short Term Disability and/or Extended Illness Bank. The employee will be contacted within 5 business days by the Leaves Administrator with a Notice of Eligibility and Rights which explain 1) if the employee is eligible for FMLA leave and/or disability or sick pay and what your available balances are; 2) what your rights and responsibilities are under the FMLA; and 3) what the employee's responsibility is for obtaining documentation (typically a Provider Certification form) and the date the documentation must be returned by.

If there is any difficulty submitting the form such as no internet access or incapacity, questions regarding the form, or to know what leave balances the employee has available, please call the Human Resources Office at 360.417.7718 or stop by the Human Resources Office located in the Annex building across from the emergency vehicle entrance to the Emergency Department. Leave balances can also be checked on the employee's most recent pay stub.

If the employee requires multiple leaves, please complete an initial leave request for each leave needed. For example, if an employee needs a leave for themselves and to take care of a family member, then two initial leave request forms are needed.

This request may be used for FMLA or discretionary leave (unpaid), as well as for paid leave such as disability, extended illness bank, or vacation/PTO pay (as applicable per division). Eligibility for FMLA, discretionary leave, and/or paid leave is determined separately. If FMLA and paid leave are approved, paid leave will be considered protected FMLA leave and counted against your FMLA leave entitlement. For more information, please review the employee's applicable collective bargaining agreement and/or applicable OMC policies.

Employees may also be eligible to receive Paid Family and Medical Leave (PFML) benefits offered by Washington state. The program operates similarly to unemployment, and if approved for benefits, PFML provides paid time off when a serious health condition prevents an employee from working, when they need to care for a family member or new child, or for certain military-related events. Leave may be job protected as well. More information about the program and to apply can be found on their website here. If there are any questions about the program, please call PFML directly at 833.717.2273.