FMLA Leave Request Form

FMLA LEAVE REQUEST FORM — WISCONSIN

Table of Contents

1. Employee Information
2. Employer Information
3. Leave Type Requested
4. Federal FMLA Overview
5. Wisconsin Family and Medical Leave Act (WFMLA)
6. Leave Schedule and Duration
7. Intermittent or Reduced Schedule Leave
8. Medical Certification
9. Job Restoration Rights
10. Benefits Continuation
11. Wisconsin-Specific Notes
12. Employee Certification and Signature
13. Employer Response

1. Employee Information

2. Employer Information

3. Leave Type Requested

Check all that apply:

Federal FMLA Qualifying Reasons (29 U.S.C. § 2612):
☐ Birth of a child and bonding
☐ Placement of a child for adoption or foster care
☐ Care for spouse, child, or parent with a serious health condition
☐ Employee's own serious health condition
☐ Qualifying exigency arising from military service of a family member
☐ Care for a covered servicemember with a serious injury or illness (Military Caregiver Leave)

WFMLA — Family Leave (Wis. Stat. § 103.10(4)(a)):
☐ Birth of a child (up to 6 weeks)
☐ Placement of a child for adoption (up to 6 weeks)
☐ As a precondition to adoption under Wis. Stat. § 48.90(2) (up to 6 weeks)

WFMLA — Family Care Leave (Wis. Stat. § 103.10(4)(b)):
☐ Care for a child, spouse, domestic partner, or parent with a serious health condition (up to 2 weeks)
☐ Care for a parent of a domestic partner with a serious health condition (up to 2 weeks)

WFMLA — Medical Leave (Wis. Stat. § 103.10(4)(c)):
☐ Employee's own serious health condition (up to 2 weeks)

4. Federal FMLA Overview

The federal Family and Medical Leave Act (29 U.S.C. §§ 2601-2654) provides eligible employees with:

• Up to 12 workweeks of unpaid, job-protected leave in a 12-month period
• Up to 26 workweeks for military caregiver leave in a single 12-month period
• Eligibility: Employed at least 12 months; worked at least 1,250 hours in the 12 months preceding leave; worksite with 50+ employees within 75 miles

5. Wisconsin Family and Medical Leave Act (WFMLA)

Under Wis. Stat. § 103.10:

Leave Entitlements (per calendar year):

Total maximum WFMLA leave: Up to 10 workweeks per calendar year (if all categories are used)

Eligibility:

• Employed for more than 52 consecutive weeks (one year)
• Worked at least 1,000 hours in the preceding 52-week period (including paid leave time)

Covered Employers:

• Employers with 50 or more permanent employees

Family Leave Timing:

• Family leave for birth/adoption must begin within 16 weeks of the birth or placement
• Leave may begin up to 16 weeks prior to the expected date of birth or placement
• Limit of one 6-week period per child, even if a new calendar year begins during the leave

Covered Family Members for Family Care Leave:

• Child, spouse, domestic partner, parent, or parent of a domestic partner

6. Leave Schedule and Duration

Type of Leave Schedule:
☐ Continuous leave (one uninterrupted block)
☐ Intermittent leave (see Section 7)
☐ Reduced schedule leave (see Section 7)

Reason for Dates Selected:
[________________________________]
[________________________________]

7. Intermittent or Reduced Schedule Leave

Complete only if requesting intermittent or reduced schedule leave.

☐ I understand that family leave for bonding under WFMLA is generally taken as a continuous block
☐ My leave is medically necessary on an intermittent basis (certification attached)
☐ Employer has agreed to non-continuous family leave arrangement

8. Medical Certification

Applicable when leave is for a serious health condition.

☐ Medical certification from a health care provider is attached
☐ Medical certification will be submitted within 15 calendar days
☐ Not applicable — leave is for birth/adoption bonding only

9. Job Restoration Rights

Under Federal FMLA:

• Restoration to the same or an equivalent position with same pay, benefits, and conditions
• Key employee exception may apply for certain highly compensated salaried employees

Under WFMLA (Wis. Stat. § 103.10(8)):

• Employees are entitled to be restored to the same position held before the leave or an equivalent position with equivalent compensation, benefits, and other terms and conditions of employment
• Employer may not discriminate or retaliate against an employee for requesting or taking WFMLA leave

☐ I acknowledge my right to job restoration upon timely return from leave
☐ I understand I must return on or before the agreed end date of my leave

10. Benefits Continuation

☐ I elect to continue group health insurance coverage during leave
☐ I understand I must continue paying my share of health insurance premiums
☐ I understand failure to pay my premium share may result in loss of coverage
☐ I wish to discuss benefit continuation options with HR

11. Wisconsin-Specific Notes

Coordination of Federal FMLA and WFMLA:

• Both laws may apply simultaneously; leave runs concurrently when both are triggered
• WFMLA uses a calendar year for measuring leave entitlement; federal FMLA uses the employer's chosen 12-month calculation method
• Track entitlements under both laws separately — an employee may exhaust one entitlement before the other

Key Wisconsin Distinctions:

Domestic Partner Coverage:

• WFMLA includes domestic partners and parents of domestic partners as covered family members
• Federal FMLA does not cover domestic partners

No Paid Family Leave Program:

• Wisconsin does not have a state-mandated paid family leave or paid sick leave program
• Proposed legislation in the 2025-2026 session would create a paid family and medical leave insurance program, but as of March 2026 it has not been enacted

Employer Posting Requirements:

• Employers must post a notice of employee rights under WFMLA in a conspicuous location
• The Wisconsin Department of Workforce Development provides required posters

12. Employee Certification and Signature

I certify that the information provided in this request is true and accurate to the best of my knowledge. I understand that providing false or misleading information may result in denial of leave, disciplinary action, or termination. I have read and understand the leave rights described in this form under both federal FMLA and the Wisconsin Family and Medical Leave Act.

13. Employer Response

To be completed by employer within five (5) business days of receiving this request.

☐ Leave request APPROVED under federal FMLA
☐ Leave request APPROVED under WFMLA (Wis. Stat. § 103.10)
☐ Leave request APPROVED under both federal FMLA and WFMLA (concurrent)
☐ Leave request DENIED — reason: [________________________________]
☐ Additional information or certification required: [________________________________]

This form is provided as a template by ezel.ai and does not constitute legal advice. Wisconsin employers should consult with qualified employment law counsel regarding compliance with Wis. Stat. § 103.10 (WFMLA) and 29 U.S.C. §§ 2601-2654 (federal FMLA).