Sample Letter from Health Care Provider Supporting Need for Leave as a Reasonable Accommodation of a Disability
(This
letter can be used if the employee has exhausted her 4 months of pregnancy or
childbirth-related disability leave, but still needs additional leave due to a
disability.)
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].
[Your name] has [optional: describe condition; note you are
not required to reveal a specific diagnosis,] a medical condition that
limits [Your name]’s major life
activities, including [fill in relevant
“major life activities,” such as: concentrating, thinking, interacting with
others, communicating, performing manual tasks, walking, standing, lifting,
bending, speaking, breathing, reading, seeing, hearing, sleeping, eating, and caring for oneself,
or the operation of a major bodily function. “Working” should be listed only if
no other activity applies].
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 [date]/is scheduled to begin on [date].
I anticipate that [Name]
will be able to return to work on [Your
health care provider must provide a return-to-work date, even if it must
be changed later – an “indefinite” leave of absence without a return-to-work
date may not be considered a reasonable accommodation].
Thank you.
[Signature]
