California: Certification of Health Care Provider for Pregnancy Disability Leave, Transfer and/or Reasonable Accommodation
Employee's Name: ________________________________________________
Please certify that, because of this patient's pregnancy, childbirth, or a related medical condition (including, but not limited to, recovery from pregnancy, childbirth, loss or end of pregnancy, or post-partum depression), this patient needs (check all appropriate category boxes):
____Time off for medical appointments
When: ____________________ Duration: ____________________
____Disability leave (Because of a patient's pregnancy, childbirth or a related medical condition, patient cannot perform one or more of the essential functions of patient's job or cannot perform any of these functions without undue risk to self, to successful completion of the pregnancy, or to other persons)
Beginning (Estimate): ____________________ Ending (Estimate): ____________________
_____Intermittent leave
Specify the intermittent leave schedule: ______________________________
Beginning (Estimate): ____________________ Ending (Estimate): ____________________
_____Reduced work schedule
Specify the reduced work schedule: ______________________________
Beginning (Estimate): ____________________ Ending (Estimate): ____________________
_____Transfer/Be assigned to a less strenuous or hazardous position or duties
Specify the medically advisable position/duties: ______________________________
Beginning (Estimate): ____________________ Ending (Estimate): ____________________
_____Reasonable accommodation(s)
Specify (can include, but is not limited to, modifying lifting requirements, providing more frequent breaks, or providing a stool or chair): ______________________________
Beginning (Estimate): ____________________ Ending (Estimate): ____________________
Health Care Provider Name (Print): ______________________________________________
Medical Health Care Specialty: ____________________ License Number: ______________
_________________________________________________________________________
Health Care Provider Signature Date
Source: California Civil Rights Department CRD-E11P-ENG
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