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