The following rules apply to any request for reasonable accommodation, transfer, or disability leave because of pregnancy.
CIVIL RIGHTS COUNCIL
CERTIFICATION OF HEALTH CARE PROVIDER FOR PREGNANCY DISABILITY LEAVE, TRANSFER AND/OR REASONABLE ACCOMMODATION
[] | 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.] | |
Beginning (Estimate): ________________________________________________________________________________________________ | ||
Ending (Estimate): _________________________________________________________________________________________________ | ||
[] | Intermittent leave. Specify medically advisable intermittent leave schedule: | |
________________________________________________________________________________________________________________ | ||
_________________________________________________________________________________________________________________ | ||
Beginning (Estimate): __________________________________________________________________________________________________ | ||
Ending (Estimate): ____________________________________________________________________________________________________ | ||
[] | Reduced work schedule. [Specify medically advisable reduced work schedule.] | |
___________________________________________________________________________________________________________________ | ||
___________________________________________________________________________________________________________________ | ||
Beginning (Estimate):___________________________________________________________________________________________________ | ||
Ending (Estimate): ______________________________________________________________________________________________________ | ||
[] | 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]. | |
______________________________________________________________________________________________________________________ | ||
______________________________________________________________________________________________________________________ | ||
Beginning (Estimate): _____________________________________________________________________________________________________ | ||
Ending (Estimate): _______________________________________________________________________________________________________ | ||
[] | Reasonable accommodation(s). [Specify medically advisable needed accommodation(s). These could include, but are not limited to, modifying lifting requirements, or providing more frequent breaks, or providing a stool or chair.] | |
____________________________________________________________________________________________________________________ | ||
_____________________________________________________________________________________________________________________ | ||
Beginning (Estimate): ___________________________________________________________________________________________________ | ||
Ending (Estimate): ______________________________________________________________________________________________________ | ||
Name, license number and medical/health care specialty [printed] of health care provider. | ||
______________________________________________________________________________________________________________________ | ||
______________________________________________________________________________________________________________________ | ||
______________________________________________________________________________________________________________________ | ||
______________________________________________________________________________________________________________________ | ||
Signature of health care provider: | ||
_____________________________________________________________________________________________________________________ | ||
Date: | ||
______________________________________________________________________________________________________________________ |
Cal. Code Regs. Tit. 2, § 11050
2. Amendment of subsections (a)(5) and (e) filed 12-9-2015; operative 4-1-2016 (Register 2015, No. 50).
3. Change without regulatory effect amending subsection (e) filed 3-20-2023 pursuant to section 100, title 1, California Code of Regulations (Register 2023, No. 12).
Note: Authority cited: Section 12935(a), Government Code. Reference: Sections 12940 and 12945, Government Code; FMLA, 29 U.S.C. § 2601, et seq., and FMLA regulations, 29 C.F.R. § 825.
2. Amendment of subsections (a)(5) and (e) filed 12-9-2015; operative 4/1/2016 (Register 2015, No. 50).
3. Change without regulatory effect amending subsection (e) filed 3-20-2023 pursuant to section 100, title 1, California Code of Regulations (Register 2023, No. 12).