<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> January 9, 2013