California Certification of Health Care Provider for Pregnancy Disability Leave, Transfer and/or Reasonable Accommodation

Entity Mandating Form: California Department of Fair Employment and Housing (DFEH)

Applicability: The Fair Employment and Housing Act gives an employee the right to request a reasonable accommodation, transfer or disability leave because of pregnancy. As a condition of granting the request, the employer may require the employee to provide written medical certification. The employer must give the employee a certification form for the employee's health care provider to complete.

Obtaining This Form: An employer may download this form directly from the DFEH website.

Additional Resources

California Department of Fair Employment and Housing