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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/68 KB)

ERD-10111 (English Print Version - pdf/18 KB)

ERD-10111-S (Spanish Print Version - pdf/82 KB)

Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.