CALIFORNIA DEPARTMENT OF FAIR EMPLOYMENT AND HOUSING
CERTIFICATION OF HEALTH CARE PROVIDER
FOR PREGNANCY DISABILITY LEAVE, TRANSFER AND/OR REASONABLE
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.
Specify when and for what duration:
A disability leave. [Because of a patient’s pregnancy, childbirth or a related medical
condition, she cannot perform one or more of the essential functions of her job or cannot
perform any of these functions without undue risk to herself, to her pregnancy’s successful
completion, or to other persons.]
Intermittent leave. Specify medically advisable intermittent leave schedule:
Reduced work schedule. [Specify medically advisable reduced work schedule.]
Transfer to a less strenuous or hazardous position or to be assigned to less strenuous or
hazardous duties [specify what would be a medically advisable position/duties].