CERTIFICATION OF HEALTH CARE PROVIDER

for Pregnancy Disability Leave, Transfer and/or Reasonable Accommodation

EmployeeName:

Please cerfy that, because of this paent’s pregnancy, childbirth, or a related medical condion (including, but not limited to,

recovery from pregnancy, childbirth, loss or end of pregnancy, or post-partum depression), this paent needs (check all appropriate

category boxes):

TIME OFF FOR MEDICAL APPOINTMENTS

When:       Duraon:

DISABILITY LEAVE (Because of a paent’s pregnancy, childbirth or a related medical condion, paent cannot

REDUCED WORK SCHEDULE

Specifythereducedworkschedule:

Beginning(Esmate):     Ending(Esmate):

TRANSFER/BE ASSIGNED TO A LESS STRENUOUS OR HAZARDOUS POSITION OR DUTIES

Specifythemedicallyadvisableposion/dues:

Beginning(Esmate):     Ending(Esmate):

REASONABLE ACCOMMODATION(S)

Specify(caninclude,butisnotlimitedto,modifyingliingrequirements,providingmorefrequentbreaks,or

providingastoolorchair):

Beginning(Esmate):     Ending(Esmate):