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Oregon BOLI OFLA/FMLA Provider Certification Template

Oregon's Bureau of Labor and Industries publishes this Word template so employers can request one certification covering both Oregon Family Leave Act and federal FMLA leave. The provider picks the qualifying condition category, from hospital care to sick child leave, describes the supporting medical facts and estimates full-time or intermittent leave. The employee then gives it to the employer.

Who completes it

The employee's or family member's health care provider completes the whole form after the employee and patient names; there are no separate employee or employer sections.

Submitting and payment

How to submit it
The provider returns the completed form to the employee, who gives it to the employer.
Who pays
The template sets no fee and names no payer for the provider's certification.

Good to know

  • Intermittent leave can be marked as one to two, two to three or three to four days per month, or explained under 'Other' with specific frequency and duration.
  • Since July 2024 OFLA mainly covers sick child, pregnancy disability and bereavement leave; leave for a serious health condition largely moved to Paid Leave Oregon.
  • Paid Leave Oregon accepts this BOLI certification as verification of a serious health condition under its rules and provider fact sheet.
  • Because it is a Word template, employers may adapt it, so the version a patient brings may differ slightly from BOLI's original.

Get the official form

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

Oregon and Federal Family and Medical Leave Health Care Provider Certification

Official pageWord file

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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

What is sick child leave on the Oregon OFLA/FMLA certification?

Category 7 covers an illness, injury or condition of the employee's child that requires home care, including conditions that are not serious health conditions. It is the OFLA-only category on this combined form; the other six track the federal serious health condition definitions printed on the back.

Does Paid Leave Oregon accept the BOLI OFLA/FMLA certification?

Yes. Paid Leave Oregon's rules (OAR 471-070-1120) and its provider fact sheet accept this BOLI form as verification of a serious health condition, so a completed copy can also support a Paid Leave Oregon benefits claim.

Who receives the completed BOLI certification?

The employee. The template says it is completed by a health care provider and returned to the employee, who then gives it to the employer. Information on it should relate only to the condition for which the employee is taking leave.