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SECTION I - EMPLOYER - DOL

Certification of Health Care Provider for Department of Labor Family Member s Serious Health Condition Wage Hour Division under the Family and Medical leave Act DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR. OMB Control Number: 1235-0003 RETURN TO THE PATIENT. Expires: 6/30/2023 The Family and Medical leave Act (FMLA) provides that an EMPLOYER may require an employee seeking FMLA leave to care for a family member with a serious health condition to submit a medical certification issued by the family member s health care provider.

request a certification for FMLA leave to bond with a healthy newborn child or a child placed for adoption or foster care. Employers must generally maintain records and documents relating to medical information, medical certifications, recertifications, or

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