(This letter can be used if the employee has exhausted her 4 months of pregnancy or childbirth-related disability leave, but still needs additional leave due to a disability.)
[Your Health Care Provider’s Letterhead]
[Date]
To whom it may concern:
I am the [treating physician, nurse practitioner, nurse midwife, licensed midwife, clinical psychologist, clinical social worker, licensed marriage or family therapist, licensed acupuncturist, physician assistant, chiropractor, social worker, or health care professional] for [Your Name].
[Your name] has [optional: describe condition; note you are not required to reveal a specific diagnosis,] a medical condition that limits [Your name]’s major life activities, including [fill in relevant “major life activities,” such as: concentrating, thinking, interacting with others, communicating, performing manual tasks, walking, standing, lifting, bending, speaking, breathing, reading, seeing, hearing, sleeping, eating, and caring for oneself, or the operation of a major bodily function. “Working” should be listed only if no other activity applies].
As a result of [Name]’s disability, [she/he] is temporarily unable to work. [She/he] needs a leave of absence for treatment and recovery. This leave [began on [date]/is scheduled to begin on [date].
I anticipate that [Name] will be able to return to work on [Your health care provider must provide a return-to-work date, even if it must be changed later – an “indefinite” leave of absence without a return-to-work date may not be considered a reasonable accommodation].
Thank you.
[Signature]