PREGNANCY ACCOMMODATION LETTER

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

Date: [Date you write the letter]
To: [Employer, human resources, or occupational health contact]

Re: [Patient's full name]
Date of birth: [Date]
Job title: [Job title, if known]

[Patient name] asked me for this letter and agreed to what it shares.

ASSESSMENT
I assessed [patient name] [in person, by video, or by phone] on [date of the visit].
Pregnancy: [Pregnant, or gave birth on date. Add weeks or the due date only if the patient agrees and the employer needs it]

LIMITATION
[What the patient can't do or needs, in plain words, e.g. pain when lifting heavy loads, needs to eat every 2 to 3 hours, or needs regular prenatal appointments]
This limitation is related to [the pregnancy, recovery from childbirth, or a related condition].

CHANGES NEEDED AT WORK
Lifting and carrying: [Limit, e.g. no lifting over 9 kg / 20 lb, nothing from the floor or above shoulder height, or none]
Breaks: [How often and how long, e.g. a 10-minute seated break every 2 hours, or none]
Sitting and standing: [e.g. a chair or stool at the workstation, or none]
Hours and schedule: [e.g. no shifts starting before 10:00, no night shifts or overtime, or none]
Remote work: [e.g. work from home on appointment days, if the job allows, or none]
Appointments: [About how often and how long, e.g. every 2 weeks for 2 hours, or none]
Tasks or hazards to avoid: [e.g. ladders, named chemicals, or none]
Other: [Any other change, or none]

DURATION
From: [Start date]
Until: [End date, the start of leave, or the review date]
Review: [Date you will reassess and update this letter]

DIAGNOSIS
[Not included, or with the patient's consent: the condition in words they agreed to]

[Your name, credentials]
[License or registration number]
[Signature]
Questions about these changes: [Practice phone or email]