Plain Text Law

Policy AM-204-7-2 Lactation Accommodation Leave Tracking Form

Published by the Baltimore City Department of Legislative Reference.

Balt., Md., Admin. Manual AM-204-7-2 (2026)

Policy AM-204-7-2 Lactation Accommodation Leave Tracking FormCopy Citation

<table class="layout-table"> <tbody> <tr> <td>Leave Used for Pay Period:</td> <td>Beginning ________</td> <td>Ending _________</td> </tr> <tr> <td>Employee Name: _______________</td> <td>I.D. ___________</td> <td></td> </tr> <tr> <td>Agency: _______________</td> <td></td> <td></td> </tr> </tbody> </table>
<strong>Week of ________________________</strong>
<table> <thead> <tr> <th>Date</th> <th>Break 1</th> <th>Break 2</th> <th>Break 3</th> <th>Total Leave</th> <th>Leave Type</th> </tr> </thead> <tbody> <tr> <td></td> <td></td> <td></td> <td></td> <td></td> <td></td> </tr> <tr> <td></td> <td></td> <td></td> <td></td> <td></td> <td></td> </tr> <tr> <td></td> <td></td> <td></td> <td></td> <td></td> <td></td> </tr> <tr> <td></td> <td></td> <td></td> <td></td> <td></td> <td></td> </tr> <tr> <td></td> <td></td> <td></td> <td></td> <td></td> <td></td> </tr> <tr> <td></td> <td></td> <td></td> <td></td> <td></td> <td></td> </tr> <tr> <td></td> <td></td> <td></td> <td></td> <td></td> <td></td> </tr> </tbody> </table>
<strong>Week of ________________________</strong>
<table> <thead> <tr> <th>Date</th> <th>Break 1</th> <th>Break 2</th> <th>Break 3</th> <th>Total Leave</th> <th>Leave Type</th> </tr> </thead> <tbody> <tr> <td></td> <td></td> <td></td> <td></td> <td></td> <td></td> </tr> <tr> <td></td> <td></td> <td></td> <td></td> <td></td> <td></td> </tr> <tr> <td></td> <td></td> <td></td> <td></td> <td></td> <td></td> </tr> <tr> <td></td> <td></td> <td></td> <td></td> <td></td> <td></td> </tr> <tr> <td></td> <td></td> <td></td> <td></td> <td></td> <td></td> </tr> <tr> <td></td> <td></td> <td></td> <td></td> <td></td> <td></td> </tr> <tr> <td></td> <td></td> <td></td> <td></td> <td></td> <td></td> </tr> </tbody> </table>
<strong> <em>I certify that the above leave was used for lactation purposes and in accordance with the terms of my lactation accommodation</em> </strong> <strong>.</strong>
<strong>Employee’s Signature ____________________ Date: __________</strong>
<strong>Supervisor Signature ____________________ Date: __________</strong>
History: January 9, 2013