Certification By Health Care Provider For Family Or Medical Leave
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1
2State of Wisconsin
Office of State Employment Relations
Division of Compensation and Labor Relations
CERTIFICATION BY HEALTH CARE PROVIDER
FOR FAMILY OR MEDICAL LEAVE
EMPLOYEE'S NAME:
PATIENT'S NAME (if other than employee):
1.
Does ________________________________________________________ have a serious health condition?*
(patient)
___
___
YES (continue with #2)
NO (provide signature and return form to address listed)
*NOTE: Wisconsin's Family and Medical Leave law (s. 103.10, Wis. Stats.) 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.
2.
Date condition commenced:
3.
Probable duration of condition / estimated date employee can return to work:
4.
Specify medical facts regarding the serious health condition:
5.
Indicate the extent to which the employee is unable to perform his or her employment duties:
Health Care Provider Name (please print): _________________________________________________________________________
Type of Practice / Medical Specialty: ______________________________________________________________________________
Business Address: ______________________________________________________________________________________________
Telephone: (_________) __________________________________
Fax: (________) _________________________________
________________________________________________________________________________
__________________________
Health Care Provider Signature
Date
Please return completed, signed form to the following address:
St. Norbert College
_________________________________________________________________________
100 Grant Street, Human Resources
_________________________________________________________________________
De Pere, WI 54115
_________________________________________________________________________
OSER-DCLR-202 (revised 3/6/13)
s. 103.10, Wis. Stats.
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