LACTATION ACCOMMODATION LETTER

[Practice name]
[Address]
[Phone and email]

Date: [Date you write the letter]
To: [Human resources, manager, or To whom it may concern]

Re: [Patient's full name]
Date of birth: [Date]

I assessed [patient name] [in person, by video, or by phone] on [date of the visit]. [Patient name] is [breastfeeding, expressing breast milk at work, or both] and asked me for this letter to support a request for accommodation at work.

ACCOMMODATION NEEDED
Breaks: [How many a day or shift, about how long each, and how far apart. Timing can vary.]
Space: [A private space other than a bathroom, and what it needs: a door that locks, a chair, a power outlet, a fridge or cooler for milk. Or: the space already provided.]
Schedule or duties: [Changes to shifts, overtime, or travel, or none]
Exposures to avoid: [Substances or tasks to avoid while nursing, and until when, or none]

REASON
[Delete this section for usual breaks and space. For needs beyond them: a plain description, such as a lactation-related condition. Name the condition only with the patient's consent.]

DURATION
From [start date] until [end date, or the date I will review these needs]. The patient will tell you if these needs end or change sooner.

The patient asked for this letter and agreed to what it shares.

[Your name, credentials]
[License or registration number]
[Signature]

To verify this letter, call [practice phone]. We will confirm only that the letter is genuine.