Employees taking state paid family and medical leave under a Sun Life private plan to care for an injured current service member need this certification from the service member's provider. It follows the FMLA military caregiver format but uses PFML family definitions, including siblings, grandparents and domestic partners. The provider documents service connection, severity and care needed.
The employer or employee completes Section 1 (dates requested and due); the employee completes Section 2 on the service member; the service member's health care provider completes Section 3, Parts A to C, and signs Section 5.
Download the current version from the source each time; forms change without notice.
Paid Family and Medical Leave (PFML) – Care for Injured Service member
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GSTDFM-10784 is for state paid family and medical leave under Sun Life private plans, while GAMSFM-11125 is for federal FMLA. The PFML version lists broader family relationships, such as sibling, grandchild, grandparent and domestic partner, and adds an employer section with request and return dates.
The form itself says its use is optional; it asks the provider for the information needed for a complete and sufficient certification. An employer may require a timely and complete certification to support the leave, whatever form carries it.
Very Seriously Ill/Injured, Seriously Ill/Injured, Other Ill/Injured, or none of the above. The first two are internal DoD casualty assistance designations used by DoD providers; 'Other' means the condition may make the member medically unfit for duty.