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FMLA Medical Leave of Absence Request - FAMU

FMLA Medical Leave of Absence Request - FAMU 2026

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The document is a Family and Medical Leave Act (FMLA) Certification of Health Care Provider Form for an employee seeking leave to care for a family member with a serious health condition. It outlines the responsibilities of the employee to complete Section I before providing it to their family member or health care provider, emphasizing the need for timely and complete medical certification. The form includes sections for employee information, health care provider details, medical facts about the family member's condition, and the amount of care needed. It also defines what constitutes a 'serious health condition' under FMLA.

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Click ‘Get Form’ to open the FMLA Medical Leave of Absence Request in the editor.
Begin by completing Section I, which requires your name, the name of the family member you will care for, and your relationship to them. If applicable, include your child's date of birth and indicate if they are incapable of self-care due to a disability.
In Section I, describe the care you will provide and estimate how much leave you will need. Ensure that all information is accurate as it supports your FMLA request.
Proceed to Section II where the health care provider must fill out their information. This includes details about the patient's condition and treatment plan. Make sure they answer all questions thoroughly.
Once completed, review all sections for accuracy before submitting. You can easily save or share the document directly from our platform for free.

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