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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

Employer’s Name

______________________________________________________

Street Address

______________________________________________________

City, State, Zip Code

______________________________________________________

Employee Name

______________________________________________________

__________________________________________________

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?

Yes

(Patient name)

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

employment duties.

_______________________________________________________________

___________________________________________________________________________________________________

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)

Form Erd-10111-F - Physician Or Practitioner Certification For Family Or Medical Leave February 2001