Physician or Practitioner Certification for Family or Medical Leave

Document Number:  ERD-10111-E

Description:  This form should be used by employers to assist in establishing leave entitlement under Wisconsin's Family and Medical Leave Law.

Comments:  This form may be reproduced by employers.

Content Contact:  Equal Rights Information

Document Attachments:

ERD-10111-E (English Electronic Version - Word/55 KB)

ERD-10111 (English Print Version - pdf/22 KB)

ERD-10111-S (Spanish Print Version - pdf/26 KB)

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