12 -- Sample doctor's letter -- LOA (00340329).DOC
Sample Letter from Health Care Provider
Supporting Need for Accommodation Under ADA or FEHA
Leave of Absence
Your Health Care Provider’s Letterhead
[Date]
To Whom It May Concern:
I am the treating [job title or description, such as physician, psychiatrist, psychologist, therapist, social worker, case worker, or health care professional] for [name of employee or applicant].
[Name] has [optional: name or description of employee’s medical condition,] a medical condition that [substantially*] limits [Name]’s major life activities, including [fill in relevant major life activities, such as: caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, or the operation of major bodily function].
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/is scheduled to begin on] [date leave is to begin].
I anticipate that [Name] will be able to return to work on [date].**
Signature and license number
*Federal law (the ADA) requires that the condition “substantially limit” a major life activity. State law (the FEHA) requires that the condition “limit” a major life activity.
**It is very important to include an estimated 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.
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