FMLA Leave Request Form - Wisconsin
FMLA Leave Request Form — Wisconsin
Before you submit: Use this form to tell your employer what leave you need. The employer must assess federal and Wisconsin coverage and eligibility separately. This request does not itself approve leave or replace the employer's required notices.
Employee and employer
| Field | Entry |
|---|---|
| Employee name | [________________________________] |
| Employee ID, if used | [________________________________] |
| Job title and worksite | [________________________________] |
| Mailing address | [________________________________] |
| Phone and email | [________________________________] |
| Employer or agency | [________________________________] |
| Supervisor or HR contact | [________________________________] |
| Date submitted | [__/__/____] |
| Date employer first learned leave might be needed, if earlier | [__/__/____] |
Leave requested
I request review under: ☐ federal FMLA ☐ Wisconsin family or medical leave ☐ both ☐ unsure; please assess both.
Reason for leave (check and complete every applicable line):
☐ Birth of my child; expected or actual date: [__/__/____].
☐ Placement of a child with me for adoption or as a precondition to adoption; expected or actual date: [__/__/____].
☐ Placement of a child with me for foster care; expected or actual date: [__/__/____].
☐ Care for a person with a serious health condition. Relationship: ☐ child ☐ spouse ☐ domestic partner ☐ parent ☐ parent of domestic partner ☐ other [____________].
☐ My own serious health condition affects my ability to perform my job duties.
☐ Military family exigency or care for a covered servicemember. Relationship and general reason: [________________________________].
☐ Other leave reason or additional explanation: [________________________________].
For a planned birth, adoption, or medical treatment, I first became aware that leave would be needed on [__/__/____]. I previously notified [name] on [__/__/____] by [method], if applicable.
Dates and schedule
| Field | Entry |
|---|---|
| First requested leave date | [__/__/____] |
| Expected last leave date or next review date | [__/__/____] |
| Estimated total time needed | [____] weeks / [____] days / [____] hours |
| Usual work schedule | [________________________________] |
| Proposed schedule during leave | [________________________________] |
☐ Continuous leave. ☐ Intermittent leave. ☐ Reduced schedule. ☐ Schedule is not yet known.
If intermittent or reduced schedule leave is requested, describe the expected frequency, duration, and dates without listing a diagnosis: [________________________________].
Records and certification
☐ I have attached information that I choose to provide with this request: [________________________________].
☐ I ask the employer to send the applicable certification form and tell me where to return it. I will provide medical details through that process rather than in this general request.
For federal FMLA certification requested by the employer, 29 C.F.R. § 825.305(b) generally allows 15 calendar days after the request, with the rule's practicability and employer-extension exceptions. I ask the employer to state the actual return date in its notice.
Employee statement
The dates and information above are accurate to the best of my knowledge. I will update the employer if the expected need or schedule changes. I understand that fraudulently obtained federal FMLA leave lacks the restoration and health-benefit protections described in 29 C.F.R. § 825.216(d).
Employee signature: [________________________________] Date: [__/__/____]
Employer receipt and routing
Received by: [________________________________] Date: [__/__/____]
Federal eligibility notice sent: [__/__/____] / ☐ pending / ☐ not applicable. Under 29 C.F.R. § 825.300(b), the federal eligibility notice is generally due within five business days after the request or knowledge that leave may qualify, absent extenuating circumstances. This is an eligibility-notice clock, not an approval deadline.
Federal rights and responsibilities notice sent: [__/__/____] / ☐ pending / ☐ not applicable.
Other employer notice sent: [type and date] / ☐ pending / ☐ not applicable.
Wisconsin leave review assigned to: [________________________________]. Wisconsin eligibility, available leave, scheduling, pay substitution, benefits, and restoration are to be determined under Wis. Stat. § 103.10 and the employer's applicable policies.
Additional information requested from employee: [________________________________].
Employer contact for follow-up: [________________________________].
Sources and References
- Wis. Stat. § 103.10: https://docs.legis.wisconsin.gov/statutes/statutes/103
- Federal FMLA notice and certification rules: https://www.ecfr.gov/current/title-29/part-825
About this template
- Last updated
- October 18, 2026
- Citations checked
- October 18, 2026
- Jurisdiction
- Wisconsin
- Category
- Employment & HR
Legal authority
- Wis. Stat. § 103.10(2)(c), (3)(b), (4)(a)
- 29 C.F.R. § 825.300(b)-(c)
- 29 C.F.R. § 825.305(b)
- 29 C.F.R. § 825.216(d)
Employment documents govern the relationship between a company and its workers, from offer letters and employment agreements through handbooks, performance reviews, and separations. Done right, they set clear expectations, protect against wrongful termination and discrimination claims, and give both sides a record to rely on. Done poorly, they invite lawsuits, agency complaints, and costly disputes.
Not legal advice
This template is provided for informational purposes. We recommend having an attorney review any legal document before signing, especially for high-value or complex matters.
Checked against the law it cites
A reviewer verified this template's legal citations against the official source on October 18, 2026.
Wis. Stat. § 103.10(2)(c) (checked October 18, 2026): "This section only applies to an employee who has been employed by the same employer for more than 52 consecutive weeks and who worked for the employer for at least 1,000 hours during the preceding 52-week period."
Wis. Stat. § 103.10(3)(b) (checked October 18, 2026): "The birth of the employee's natural child, if the leave begins within 16 weeks of the child's birth."
Wis. Stat. § 103.10(4)(a) (checked October 18, 2026): "Subject to pars. (b) and (c), an employee who has a serious health condition which makes the employee unable to perform his or her employment duties may take medical leave for the period during which he or she is unable to perform those duties."
29 C.F.R. § 825.300(b)(1) (checked October 18, 2026): "When an employee requests FMLA leave, or when the employer acquires knowledge that an employee's leave may be for an FMLA-qualifying reason, the employer must notify the employee of the employee's eligibility to take FMLA leave within five business days, absent extenuating circumstances."
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