FMLA - Certification of Health Care Provider Forms

Note: Effective January 1, 2014, all FMLA paperwork as well as decisions regarding an employee’s eligibility for FMLA leave will be administered by the FMLA Coordinator. The FMLA Coordinator can be reached at fmla@minneapolismn.gov or 612-673-5460 and will provide the employee with the necessary forms.

In January of 2009, the Department of Labor issued four (4) separate Certification of Health Care Provider forms that have been adapted for City use. Listed below is a short description of each form, when it should be used and a link to the form.

1. Employee’s Own Serious Health Condition – This form should be used when the employee is requesting FMLA leave to care for their own serious health condition.

This form should be given to the employee for completion who in turn will give it to their appropriate health care provider for completion.

Certification of Health Care Provider Form for an Employee’s Serious Health Condition (Word)

2. Family Member’s Serious Health Condition – This form should be used when the employee is requesting FMLA leave to care for employee’s spouse, registered domestic partner, son, daughter or a parent with a serious health condition.

This form should be given to the employee for completion who in turn will give it to their appropriate health care provider for completion.

Certification of Health Care Provider Form for a Family Member’s Serious Health Condition (Word)

3. Military Family Leave (a.k.a. "Qualifying Exigency Leave") – This form should be used when the employee needs to take leave for a qualifying exigency arising from the fact that the employee’s spouse, registered domestic partner, son, daughter or parent is a member of any branch of the military, including the National Guard or Reserves, who is deployed or called to duty in a foreign country.

This form should be given to the employee for completion who in turn will gather the necessary military orders or other documentation needed to approve the leave.

Certification of Qualifying Exigency for Military Family Leave (Word)

4. Certification for Serious Injury or Illness of Covered Service Member for Military Family Leave - This form should be used when the employee needs to care for a covered service member with a serious injury or illness; and the employee is the spouse, registered domestic partner, son, daughter, parent or next of kin of the service member.

This form should be given to the employee for completion who in turn will give it to a United States Department of Defense health care provider or other authorized health care provider for completion.

Certification for Serious Injury or Illness of Covered Service Member for Military Family Leave (Word)

Last updated Jul 28, 2016

QUICK LINKS

Home

Contact us

Email updates

Find a service

About this site

For employees

Accessibility:
For reasonable accommodations or alternative formats, contact 311.
People who are deaf or hard of hearing can use a relay service to call 311 at 612-673-3000.
TTY users can call 612-673-2157 or 612-673-2626.

Para asistencia 612-673-2700, Yog xav tau kev pab, hu 612-637-2800, Hadii aad Caawimaad u baahantahay 612-673-3500. 

CONNECT

311 call center

TTY relay service

 

facebook25x25 twitter25x25 youtube25x25 Minneapolis311icon logo tv 14 footer icon image linkedin_32x32




mpls-logo-white120