Physician or Practitioner Certification
State of Wisconsin
Department of Workforce Development
For Family or Medical Leave
Equal Rights Division
Personal information you provide may be used for secondary purposes. See Section15.04 (1)(m), Wisconsin Statutes for details.
Dear Physician or Practitioner:
To assist in establishing leave entitlements under Wisconsin’s Family and Medical Leave Law
(Section103.10 Wisconsin Statutes), please answer the questions that are checked below and return
this certification to
City, State, Zip Code
Patient’s Name (if not employee)
Employer, please check the appropriate box (es) below identifying the information you need
from the physician or practitioner.
Does ___________________________have a serious health condition?
Note: Wisconsin’s Family and Medical Leave Law (Section 103.10 Wisconsin Statutes) defines a
serious health condition as a disabling physical or mental illness, injury, impairment or condition
involving either 1) Inpatient care in a hospital, or 2) Outpatient care that requires continuing treatment
or supervision by a health care provider.
What date did the condition begin? __________________________________________________
What is the probable duration of the condition? ________________________________________
Specify medical facts regarding the serious health condition (diagnosis not required).
Please indicate the extent to which the employee is unable to perform his or her
Physician/Practitioner Name (Please Print) ___________________________________________________
Physician’s Signature ________________________________ Date Signed ____________________
Note to Employer: this information should be retained in a confidential medical file.
(This suggested form may be reproduced by employers.)
ERD-10111-F (R. 02/2001)