[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 [Name].
[Name] is nursing her child and requires lactation accommodation in her workplace. Both federal and state laws require employers to provide reasonable break time for an employee to express breast milk for her nursing child. The employer must provide a place, other than a bathroom, that is shielded from view and free from intrusion from coworkers and the public, which may be used by an employee to express breast milk. 29 U.S.C. § 207(r); CA Labor Code §§ 1030-1033; 2 Cal. Code Regs. §§ 11035(s)(5), 11040.
This lactation accommodation became medically advisable on [Date]. At this time, I anticipate that [Name] will need this accommodation for [duration of accommodation].
Thank you.
[Signature]