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Pregnancy Confirmation Form
FOR EMPLOYEE BIRTH MOTHER
Employee Information (to be completed by Employee): PLEASE PRINT
Employee Name:

Employee Number:

Phone Number:

Date:

Supervisor:

Human Resource Contact:

Examining Health Care Provider Report (to be completed by Health Care Provider):
Anticipated Date of Delivery:

Diagnosis: Pregnancy

Are there any known or expected pregnancy or delivery complications*?

*For complications other than Cesarean section a WH-380 E will need to be completed.
Health Care Provider Printed Name:

Health Care Provider Signature:

Health Care Provider Address:

Health Care Provider Phone Number:

Send the completed form and/or verification documents to:
Marathon Petroleum - Absence Management
539 South Main Street, Room D-03-126
Findlay, OH 45840
Or by email to
[email protected]
or by fax to 419-421-3057

IMPORTANT
*If you have complications of pregnancy or delivery which may qualify you for sick benefits (separate from
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