Family And Medical Leave - Employee Request - State Of Wisconsin Office Of State Employment Relations

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State of Wisconsin
Office of State Employment Relations
Division of Compensation and Labor Relations
FAMILY AND MEDICAL LEAVE - EMPLOYEE REQUEST
SECTION 1: For completion by the EMPLOYEE
Employee Name:
Employee Home Address:
Home Phone Number:
Work Phone Number:
Email:
State Agency:
Division/Office:
Work Address:
Reason for Leave (Check all applicable):
Birth/Adoption/Pre-Adoptive Foster Care
Foster Placement
Employee's Own Serious Health Condition (may require medical certification)
To Care for Family Member (including domestic partner or domestic partner's parent), Military
Servicemember, or Veteran with a Serious Health Condition* (may require medical certification)
For a Qualifying Exigency due to military deployment to a foreign country of a spouse, son, daughter,
or parent in the regular or reserve armed forces (certification may be required)
* When Family and Medical Leave is needed to care for a family member, servicemember, or veteran, you must
state the care you will provide and an estimate of the time period during which this care will be provided, including
a schedule of intermittent leave or leave on a reduced work schedule, if requested.
Anticipated Begin Date of Leave:
Anticipated End Date of Leave:
Briefly Explain Reason for Leave. If leave is to care for someone, or for a military qualifying exigency, please
indicate the other person's name and your relationship to that person. If leave is to care for a domestic partner or
a domestic partner's parent, please complete and sign the back of this form.
Substitution of Paid Leave:
Please indicate if you would like to use paid leave during your absence and
how many hours you plan to use (to the extent provided by law, labor agreement, and workplace leave policies).
Attach a completed leave report if required.
Vacation (_____ hours)
Sabbatical (_____ hours)
Personal/Floating Holiday (_____ hours)
Sick Leave (_____ hours)
Compensatory Time (_____ hours)
Other: ________________ (_____ hours)
I authorize the appointing authority to obtain any necessary information regarding my request for family and
medical leave.
Employee Signature:_________________________________________
Date:______________________________
OSER-DCLR-201 (rev. 3/4/13)
s.103.10, Wis. Stats.

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