[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].
[Name] has a condition related to [pregnancy or childbirth]. [Note: This can be any physical or mental condition that is intrinsic to pregnancy or childbirth, including, but not limited to, lactation. You do NOT need to reveal a diagnosis or details of the condition, but you do need to state that the patient has a condition related to pregnancy or childbirth.]
As a result of [Name]’s condition, it is medically advisable that she receive the following accommodation: [Describe requested accommodation here. E.g., to avoid lifting over [X] lbs., to avoid climbing ladders, to avoid exposure to toxic fumes, permission to drink water or snack during her shift, a larger uniform, a modified work schedule, more frequent bathroom breaks, a stool or chair to sit on, additional break time and a private space to express breast milk, a temporary transfer to a less strenuous or hazardous position].
This accommodation became medically advisable on [Date]. At this time, I anticipate that
[Name] will need this accommodation for [duration of accommodation]. Thank you.
[Signature]