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

Published by the Baltimore City Department of Legislative Reference.

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

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


    <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*