Outdated or Unsupported Browser Detected
DWD's website uses the latest technology. This makes our site faster and easier to use across all devices. Unfortunatley, your browser is out of date and is not supported. An update is not required, but it is strongly recommended to improve your browsing experience. To update Internet Explorer to Microsoft Edge visit their website.
Document Number: ERD-10110
Description: This form may be used 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 Attachment: ERD-10110 (pdf/13 KB)
Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.