Fillable Family Medical Leave Act (FMLA) Certification of Adoption (City of Brockton, MA)

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Family Medical Leave Act (FMLA) Certification of Adoption (City of Brockton, MA)

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Family Medical Leave Act (FMLA)
Certification of Adoption or Foster Care Placement
Failure to fully complete this form could result in an initial denial of an FMLA Leave or a delay in
approval of an FMLA Leave for the employee. Where the need for leave is foreseeable, such as for an
expected adoption or foster care placement, an employee provides at least 30 days advance notice of the need
for leave to the supervisor whenever possible.
The employer must give the employee at least 15 calendar days to provide the certification. If the employee
fails to provide complete and sufficient medical certification, his or her FMLA leave request may be denied. 29
C.F.R. § 825.313. Information about the FMLA may be found https://www.dol.gov/agencies/whd/fmla. This
information includes the anticipated timing and duration of the leave.
Section I: To be completed by Employee
INSTRUCTIONS: Ensure that Sections I and II are completed before giving this form to the
professional/agency. By signing this form, you represent that the information you provided is true and correct.
Unless advised otherwise in writing, you have 15 calendar days to return this form to your
supervisor/responsible administrator.
Qualifying Event for which leave is being requested: ( ) Adoption ( ) Foster Care Placement
Employee name: ______________________ Employee’s job title: __________________________
Employer name: _________________________________ Date: _________________ (mm/dd/yyyy)
The medical certification must be returned by _________________________________(mm/dd/yyyy)
(Must allow at least 15 calendar days from the date requested, unless it is not feasible despite the employee’s
diligent, good faith efforts.)
Section II: Amount of Leave Needed
Your answer should be your best estimate based upon your knowledge and experience to determine FMLA
coverage.
Provide your best estimate of the beginning date ___________________ (mm/dd/yyyy) and end date
________________ (mm/dd/yyyy) for the period of requested leave.
Anticipated or actual placement date: _________________________________________________
If leave is necessary prior to the date of adoption/foster care placement, such as for court appearances,
counseling, etc., indicate the date(s) and reason(s) below:
Date
Reason – provide brief description
You have 30 calendar days from the date of the event to request eligible benefit changes by submitting a
Benefits Enrollment/Change Form located in the Employee Health Benefits section of the Human Resources
website.
Section III: For Completion by the Professional Agency in Charge of Placement
INSTRUCTIONS: Please provide the following information and be sure to sign the form representing that the
information provided is accurate.
I,_____________________, attest that I am in the process of _____________ a child. I am requesting leave
under the Family and Medical Leave Act for time needed to fulfill prerequisites prior to the placement and/or
for bonding leave after the placement of the child in my home. As per the City of Brockton’s Family Medical
Leave Policy, I will provide substantiation above and as warranted throughout the placement process.
Employee Signature: _________________________________ Date: ________________(mm/dd/yyyy)
Professional/Agency Name:______________________________________________________
Address: ___________________________ City, State, Zip _____________________________
Telephone: ________________________ Fax: _______________________________________
Anticipated or actual placement date: _____________________________________________
Professional/Agency Contact Name: ________________________ Phone: _________________
Professional/Agency Signature: __________________ Date Signed:__________ (mm/dd/yyyy)
Type(s) of documentation attached/to be provided at a later date (if applicable):
Foster care/adoption placement letter.
Adoption court documents.
Birth certificate/certification of birth.
Adoption/foster care agency documents for pre-placement activities.
Other [explain]:________________________________________
_________________________________________________________
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Family Medical Leave Act (FMLA) Certification of Adoption (City of Brockton, MA)

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Completed 31 January 2021

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