University of Wisconsin – Oshkosh
CERTIFICATION BY PHYSICIAN OR PRACTITIONER
FOR FAMILY & MEDICAL LEAVE
Employee’s Name:
Patient’s Name (if other than employee):
Yes 
1. Is this a serious health condition for the patient?*
No 
*NOTE: The Federal and Wisconsin Family and Medical Leave laws define a “serious health condition” as: A
physical or mental illness, injury, impairment or condition involving either: 1) inpatient care in a hospital, or 2)
outpatient care that requires more than 3 days absence from work, school, or other regular activities and
continuing treatment or supervision by a health care provider, or 3) continuing treatment by a health care
provider for a chronic or long-term health condition which, if not treated, would likely result in a period of
incapacity of more than 3 days.
2. Date the condition commenced for the patient:
3. Patient was seen by me and treated for this serious health condition on the
following dates:
4. Probable duration of condition:
5. Specify the medical facts regarding the serious health condition (diagnosis not
required):
6. Indicate the extent to which the employee is unable to perform his or her
employment duties:
Physician/Practitioner Name (please print)
Phone Number
Physician/Practitioner Signature
Date
Please return completed, signed form to the following address:
University of Wisconsin – Oshkosh
Office of Human Resources
328 Dempsey Hall
800 Algoma Boulevard
Oshkosh, WI 54901
Fax: 920-424-2021