Wisconsin Family and Medical Leave Employee Medical Certification Form

Author: Katherine Hinde, Littler

When to Use

A covered Wisconsin employer may use this form if it requires an employee to provide a medical certification supporting a request to take leave for the employee's own serious health condition under the federal Family and Medical Leave Act (FMLA) and/or the Wisconsin Family and Medical Leave Act (WFMLA).

Employer coverage under these laws is as follows:

• The FMLA covers employers that employ 50 or more employees in 20 or more workweeks in the current or preceding calendar year and that are engaged in commerce or in any industry or activity affecting commerce.
• The WFMLA covers employers that employ 50 or more individuals on a permanent basis, during at least six of the past 12 calendar months. The law does not indicate whether the 50 or more employees refers to employees in Wisconsin or all employees. The more conservative approach is to assume that the law refers to the number of employees overall. 

Customizable Form