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Minnesota Paid Leave Safety Leave Certification Form

Minnesota Paid Leave uses this form to decide safety leave when the applicant, or a family member they support, is a survivor of domestic abuse, sexual assault or stalking. Safety leave covers time to seek medical care or counseling, get victim services, find or move to a safe home, or get legal help or go to court. An approved certifier who supports the applicant completes the certification.

Who completes it

The applicant completes Section 1, and Section 2 when applying as a caregiver for a family member. An approved certifier, such as a licensed healthcare or mental health professional, completes Section 3 with their professional role, email, organization and, if licensed by a government body, a license or badge number, then signs.

Submitting and payment

How to submit it
The applicant uploads the completed file, or photos or a scan of a printed copy, at paidleave.mn.gov with the Paid Leave application or later through their Paid Leave account or by mail; the certifier may also fax it to Paid Leave.

Good to know

  • Approved certifiers include licensed healthcare and mental health professionals, domestic abuse advocates, sexual assault counselors, court victim's advocates, judges, prosecutors, probation officers, Title IX coordinators and law enforcement officers.
  • A license, practice or badge number is required only from certifiers licensed by a government body, which includes clinicians. The certifier also writes the survivor's name as it appears on official documents.
  • The employer may ask the applicant for the completed form, but Paid Leave does not share it. The employer only confirms the leave dates and does not decide eligibility.
  • Caregivers applying for a survivor skip the signature in Section 1 and sign the family relationship section instead. Current version: SafetyCert v 3, April 2026.

Get the official form

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

Minnesota Paid Leave Safety Leave Certification Form

Official pagePDF

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.

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Frequently asked questions

Who can complete Minnesota's safety leave certification?

An approved certifier who is supporting the applicant. Examples printed on the form are licensed healthcare and mental health professionals, domestic abuse advocates, sexual assault counselors, court victim's advocates, judges, referees, court administrators, prosecutors, probation officers, Title IX coordinators and law enforcement officers. Another professional able to attest to the need can describe their role.

What can Minnesota Paid Leave safety leave be used for?

Seeking medical care or counseling, getting services from an organization that helps victims of domestic violence, sexual assault or stalking, finding or moving to a safe living situation, and getting legal support or going to court. It applies to survivors and to people supporting a family member who is a survivor.

Does the employer see the Minnesota safety leave form?

Paid Leave says it will not share the form with the employer. The employer may still ask the applicant to share the completed form, and the applicant will need to provide it. The employer's role in the claim is to confirm the dates entered in the application.