"Request for Lactation Accommodation" - City and County of San Francisco, California

Request for Lactation Accommodation is a legal document that was released by the Department of Human Resources - City and County of San Francisco, California - a government authority operating within California. The form may be used strictly within City and County of San Francisco.

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  • Released on August 1, 2017;
  • The latest edition currently provided by the Department of Human Resources - City and County of San Francisco, California;
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City and County of San Francisco
Department of Human Resources
Carol Isen
Connecting People with Purpose
www.sfdhr.org
Human Resources Director
PLEASE RETURN THIS FORM TO YOUR DESIGNATED HR PERSONNEL AT LEAST 10 BUSINESS DAYS BEFORE
YOUR ANTICIPATED RETURN FROM CHILD BONDING LEAVE.
New Request
Request for Alteration
Name: ____________________________ DSW#: _____________________Class/Title: ___________________________
Address: _________________________________City:_________________________ State: ______ Zip: _____________
Contact No.: _______________________ Personal Email: ______________________________Dept.: _______________
Supervisor: __________________________ Employment Status:
Permanent
Probationary
Temporary
Provisional
Exempt
Birthdate of Child: _____/_____/_____
I wish to use accrued
SP
VA
CTO
FH
:
during my unpaid breaks.
Start Date for Requested Accommodation: _____/_____/_____
Requested Number of Breaks per Day: __________________
-OR-
The Department may provide a flexible
First Lactation Break
Second Lactation Break
schedule, allowing you to make up unpaid
Requested Start and End Time:
Requested Start and End Time:
break time if it is feasible given the operational
____:_____ to _____:_____
_____:_____ to _____:_____
_
demands of the Department.
I am requesting a schedule that will allow me
Third Lactation Break
Fourth Lactation Break
to make up unpaid break time and work the full
Requested Start and End Time:
Requested Start and End Time:
amount of my regularly scheduled hours.
_____:_____ to _____:_____
_____:_____ to _____:_____
_
______________________________________
__________________________
__
Employee Signature
Date
YOU MAY BE CONTACTED BEFORE YOUR RETURN TO WORK TO DISCUSS THE REQUESTED LACTATION
ACCOMMODATION AND ASSIST YOU IN TRANSITIONING BACK TO THE WORKPLACE AS A NURSING PARENT.
APPROVE DENY
PRINT NAME/TITLE
SIGNATURE
DATE
1
(Attach Reason
)
(Employee’s Supervisor)
(Personnel Officer/Designee)
c: Leave/Medical File
1
A request for lactation accommodation must be approved unless the requested break time will seriously disrupt the operations of the Department.
th
One South Van Ness Avenue, 4
Floor ● San Francisco, CA 94103-5413 ● (415) 557-4800
(Rev. 08/2017)
City and County of San Francisco
Department of Human Resources
Carol Isen
Connecting People with Purpose
www.sfdhr.org
Human Resources Director
PLEASE RETURN THIS FORM TO YOUR DESIGNATED HR PERSONNEL AT LEAST 10 BUSINESS DAYS BEFORE
YOUR ANTICIPATED RETURN FROM CHILD BONDING LEAVE.
New Request
Request for Alteration
Name: ____________________________ DSW#: _____________________Class/Title: ___________________________
Address: _________________________________City:_________________________ State: ______ Zip: _____________
Contact No.: _______________________ Personal Email: ______________________________Dept.: _______________
Supervisor: __________________________ Employment Status:
Permanent
Probationary
Temporary
Provisional
Exempt
Birthdate of Child: _____/_____/_____
I wish to use accrued
SP
VA
CTO
FH
:
during my unpaid breaks.
Start Date for Requested Accommodation: _____/_____/_____
Requested Number of Breaks per Day: __________________
-OR-
The Department may provide a flexible
First Lactation Break
Second Lactation Break
schedule, allowing you to make up unpaid
Requested Start and End Time:
Requested Start and End Time:
break time if it is feasible given the operational
____:_____ to _____:_____
_____:_____ to _____:_____
_
demands of the Department.
I am requesting a schedule that will allow me
Third Lactation Break
Fourth Lactation Break
to make up unpaid break time and work the full
Requested Start and End Time:
Requested Start and End Time:
amount of my regularly scheduled hours.
_____:_____ to _____:_____
_____:_____ to _____:_____
_
______________________________________
__________________________
__
Employee Signature
Date
YOU MAY BE CONTACTED BEFORE YOUR RETURN TO WORK TO DISCUSS THE REQUESTED LACTATION
ACCOMMODATION AND ASSIST YOU IN TRANSITIONING BACK TO THE WORKPLACE AS A NURSING PARENT.
APPROVE DENY
PRINT NAME/TITLE
SIGNATURE
DATE
1
(Attach Reason
)
(Employee’s Supervisor)
(Personnel Officer/Designee)
c: Leave/Medical File
1
A request for lactation accommodation must be approved unless the requested break time will seriously disrupt the operations of the Department.
th
One South Van Ness Avenue, 4
Floor ● San Francisco, CA 94103-5413 ● (415) 557-4800
(Rev. 08/2017)