Try for free

Oregon DAS OFLA/FMLA Certification (State Employees)

Oregon state agencies use this Department of Administrative Services form when a state employee requests OFLA or FMLA leave for their own or a covered family member's health condition. The provider selects the qualifying condition category, explains the medical facts and estimates full-time, intermittent or reduced-schedule leave. The completed form goes to the agency contact named on page 2.

Who completes it

The employee completes Section I with their name, OR number and the patient's relationship; the physician or other health care provider completes Section II on medical facts and leave needed and signs Section III.

Submitting and payment

How to submit it
The provider returns the form to the patient or faxes it to the agency contact listed at the bottom of page 2; it is due within 15 days of the agency's request for certification.
Who pays
The form sets no fee and names no payer for the provider's certification.

Good to know

  • Reduced-schedule leave has its own question, separate from intermittent leave, so the specific reduced schedule is described rather than only a frequency.
  • Page 3 defines the seven categories, including sick child leave for serious and non-serious conditions, and asks providers not to give genetic information.
  • An adult child counts as a family member only when incapable of self-care because of a mental or physical disability.
  • Military caregiver leave uses DAS's separate FMLA Military Healthcare Certification (PD 615B). A fillable Word version of this form is also posted.

Get the official form

Download the current version from the source each time; forms change without notice.

Health Care Provider Certification for Serious Health Condition of Employee and/or Covered Family Member under the Oregon Family Leave Act (OFLA) and Federal Family and Medical Leave Act (FMLA)

Official pagePDFWord file

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

See how Vero Documents works

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

Who uses the Oregon DAS OFLA and FMLA certification?

Oregon state agency employees. It is the statewide form in the Department of Administrative Services Family Medical Leave Toolkit. Private employers in Oregon can use BOLI's templates or the federal WH-380 forms instead.

What is the deadline to return the Oregon DAS certification?

Section I says the form should go back to the agency contact within 15 days of the request for medical certification. The provider can hand it to the patient or fax it to the agency number printed at the bottom of page 2.

Can the provider complete the DAS form electronically?

Yes. Besides the 3-page printable PDF (version dated July 2024), DAS posts a fillable Word version of the same certification. Both versions ask the same questions in Sections I to III.