Vermont Family and Medical Leave Family Member Medical Certification Form

Author: Katherine Hinde, Littler

When to Use

A covered Vermont employer may use this form if it requires an employee to provide a medical certification supporting a request to take leave to care for a family member with a serious health condition under the federal Family and Medical Leave Act (FMLA) and/or the Vermont Parental and Family Leave Act (VPFLA).

Employer coverage under these laws is as follows:

• The FMLA covers employers that employ 50 or more employees in 20 or more workweeks in the current or preceding calendar year and that are engaged in commerce or in any industry or activity affecting commerce.
• Under the VPFLA, employers with 10 or more employees who work an average of at least 30 hours per week must provide parental leave, and employers with 15 or more employees who work an average of at least 30 hours per week must provide both parental and family leave. The VPFLA does not indicate whether the number of employees refers to employees in Vermont or all employees. The more conservative approach is to assume that the law refers to the number of employees overall.

Customizable Form