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Paid Leave Oregon Safe Leave Verification (PL Form 829)

Paid Leave Oregon's safe leave covers paid time off when a claimant, their child or a dependent is a survivor of sexual assault, domestic violence, harassment, bias crimes or stalking. PL Form 829 is one way to verify that status. A health care provider or mental health professional who treated the person can complete its 'Other' verification section.

Who completes it

The claimant fills in the Claimant Information section; one verifier completes a verification section: a law enforcement officer, a Title IX coordinator, or under 'Other' a health care provider, licensed mental health professional or counselor, attorney, clergy member, Department of Justice victim services employee or victim services provider.

Submitting and payment

How to submit it
The claimant uploads the completed form to their Frances Online account after filing, or mails it with the Paid Leave Application for Benefits.
Who pays
The form sets no fee and names no payer for the verifier's time.

Good to know

  • The 'Other' section asks for the date of contact, profession and license number if relevant, then a checkbox stating whether this is or is not a safe leave related situation.
  • Qualifying needs include medical treatment for injuries, counseling, victim services, legal or police help and court hearings, and moving or securing the home.
  • A police report, protective order, Title IX complaint or documentation from a qualifying professional can be sent instead of this form.
  • If the leave involves the claimant's child, the child must be under 18, or an adult dependent whose disability limits independent living.

Get the official form

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

Verification of Safe Leave Form

Official pagePDF

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.

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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.

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

Frequently asked questions

Can a health care provider verify Paid Leave Oregon safe leave?

Yes. Health care providers and licensed mental health professionals or counselors are among the verifiers listed in the 'Other' section of PL Form 829, alongside attorneys, clergy, Department of Justice victim services staff and victim services providers who helped the person receive treatment, counseling or relocate.

Does the safe leave verification form ask for a diagnosis?

No. The verifier's section asks for name, title, date of contact, profession, license number if relevant, employer and contact details, and a checkbox confirming whether the situation is or is not safe leave related. It does not ask for diagnosis or treatment details.

What can a claimant send instead of PL Form 829?

A copy of a police report, a protective order or other evidence from a court, agency, Title IX coordinator or attorney, a formal Title IX complaint, or documentation from a law enforcement officer, health care provider, counselor, clergy member or victim services provider.