Route this form to:
U Wide Form
Family and Medical Leave Act (FMLA):
Rev: April 2017
Certification for Birth/Care of Newborn
NOTE: Failure to fully complete this form could result in an initial denial of an FMLA leave or a delay in approval
of an FMLA leave for the employee. Where the need for leave is foreseeable, such as for an expected birth, an
employee provides at least 30 days advance notice of the need for leave to the supervisor/responsible administrator
whenever possible. This information includes the anticipated timing and duration of the leave.
SECTION I: For Completion by the SUPERVISOR/RESPONSIBLE ADMINISTRATOR OR EMPLOYEE
INSTRUCTIONS: The Family and Medical Leave Act (FMLA) provides that an employer may require an employee
seeking FMLA protections because of a need for leave due to a birth to submit a medical certification issued by the health
care provider. Ensure that Sections I and II are completed before giving this form to the health care provider.
Employer name including department/unit:
Supervisor/Responsible administrator name:
Employee’s job title:
Employee’s regular work schedule:
SECTION II: For Completion by the EMPLOYEE
INSTRUCTIONS: Ensure that Sections I and II are complete before giving this form to the health care provider. By signing
this form, you represent that the information you provided is true and correct. Unless advised otherwise in writing, you
have 15 calendar days to return this form to your supervisor/responsible administrator.
Registered same-sex domestic partner
Length of time requested for leave for birth and/or care of newborn:
Signature of employee:
SECTION III: For Completion by the HEALTHCARE PROVIDER
INSTRUCTIONS: Please provide the following information and be sure to sign the form.
Provider’s name and business address:
Type of practice/medical specialty:
(Anticipated) date of birth:
Telephone (with area code):
Fax (with area code):
Signature of Authorized Health Care Provider:
The University of Minnesota is an equal opportunity educator & employer.
2009 by the Regents of the University of Minnesota.
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