OR PFML provides up to 12 weeks of paid leave (plus 2 weeks for pregnancy-related conditions)

Benefits range from 65-100% of average weekly wage depending on income level

Covers family leave, medical leave, and safe leave (domestic violence, sexual assault, stalking)

Employment / FMLAmoderate

Oregon Paid Family and Medical Leave Application

OR PFML · Oregon Employment Department

Application for Paid Leave Oregon. Provides up to 12 weeks of paid leave for medical conditions, family bonding, caregiving, or safe leave purposes.

Form Details

Total fields: 34
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Filled by: patient
Frequency: per incident
State-specific: Yes — form may vary by state

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Where to Submit This Form

🌐

Frances Online portal (recommended)

https://www.oregon.gov/employ/PFMLI/Pages/default.aspx

Apply through Oregon's Frances Online system.

Filing Deadline

File within 30 days of the start of leave. Applications can be submitted up to 30 days before anticipated leave.

Required Attachments

📎 Medical certification for serious health condition or family member care
📎 Documentation of qualifying event (bonding, safe leave, etc.)
📎 Employer information

Processing Time

Approximately 2-4 weeks from receipt of a complete application.

What Happens Next

Oregon Employment Department will review and determine eligibility. If approved, benefits are based on wages (up to 100% of the state average weekly wage).

Tips for This Form

✓ OR PFML provides up to 12 weeks of paid leave (plus 2 weeks for pregnancy-related conditions)
✓ Benefits range from 65-100% of average weekly wage depending on income level
✓ Covers family leave, medical leave, and safe leave (domestic violence, sexual assault, stalking)
✓ More info: https://www.oregon.gov/employ/PFMLI/

More Employment / FMLA Forms

FMLA Certification - Employee's Serious Health Condition

WH-380-E · U.S. Department of Labor

Certification of Health Care Provider for Employee's Serious Health Condition. Medical certification for FMLA leave for the employee's own condition.

FMLA Certification - Family Member's Serious Health Condition

WH-380-F · U.S. Department of Labor

Certification of Health Care Provider for Family Member's Serious Health Condition. Medical certification when employee needs leave to care for a family member.

FMLA Notice of Eligibility and Rights & Responsibilities

WH-381 · U.S. Department of Labor

Notice of Eligibility and Rights & Responsibilities. Employer must provide within 5 business days of FMLA leave request, stating whether employee is eligible.

FMLA Designation Notice

WH-382 · U.S. Department of Labor

Designation Notice. Employer designates leave as FMLA-qualifying or denies it. Must be provided within 5 business days of receiving sufficient certification.

FMLA Certification - Qualifying Exigency (Military)

WH-384 · U.S. Department of Labor

Certification of Qualifying Exigency for Military Family Leave. For leave due to a covered family member's active duty or call to active duty.

FMLA Certification - Serious Injury/Illness of Servicemember

WH-385 · U.S. Department of Labor

Certification for Serious Injury or Illness of Covered Servicemember for Military Family Leave (current servicemember).

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the Oregon Employment Department or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.