FAMILY AND MEDICAL LEAVE ACT (FMLA) CERTIFICATION FORM 2026

1. Click ‘Get Form’ to open the FAMILY AND MEDICAL LEAVE ACT (FMLA) CERTIFICATION FORM in the editor.
2. Begin by filling out the Employee’s Section. Enter your name, Banner ID, and department. If you are not the patient, provide the patient's name.
3. Sign the Medical Release section to authorize the release of necessary medical information. Ensure you date your signature accurately.
4. Indicate the reason for FMLA leave by checking the appropriate box related to your medical condition or that of a family member.
5. In the Provider’s Section, ensure all medical details are filled out completely. This includes dates of treatment and any relevant medical facts supporting your request.
6. Have your healthcare provider sign and date their section, including their contact information and tax ID number.
7. If applicable, complete the Birth/Placement of a child section with required documentation dates.

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