Department of Human Resources

FAMILY MEMBER FMLA LEAVE

GUIDELINES FOR EMPLOYEE:

1. Complete the sections, “Employee’s Name” and “Patient’s Name” on page one of the Certification of Health Care Provider. Complete the section on page three above the signature area which asks for details on the leave need. Sign and provide to the Health Care Provider for completion.

2. The employee must have the Certification of Health Care Provider completed by the health care provider and returned to UMD Department of Human Resources who reviews the FMLA certification for completeness and appropriateness under the rules. All medical forms and information are retained in a separate, confidential file.