Supporting Need for Accommodation Under ADA or FEHA
Leave of Absence
Your Health Care Provider’s Letterhead
[Date]
To Whom It May Concern:
I am the treating [job title or description, such as physician, psychiatrist, psychologist, therapist, social worker, case worker, or health care professional] for [name of employee or applicant].
[Name] has [optional: name or description of employee’s medical condition,] a medical condition that [substantially*] limits [Name]’s major life activities, including [fill in relevant major life activities, such as: caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, or the operation of major bodily function].
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/is scheduled to begin on] [date leave is to begin].
I anticipate that [Name] will be able to return to work on [date].**
Signature and license number