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MADISON METROPOLITAN SCHOOL DISTRICT
Department of Human Resources

PHYSICIAN’S PREGNANCY CONFIRMATION FORM
PREGNANCY NOTICE - EMPLOYEE OR EMPLOYEE’S SPOUSE/PARTNER
Within the last two months my physician has confirmed that I am / my spouse/partner is pregnant
as reported below.
Employee Name:

______________________________________________________

Employee Address:

______________________________________________________

Employee Phone Number:

______________________________________________________

School or Department:

______________________________________________________

--------------------------------------------------------------------------------------------------------------------PHYSICIAN’S PREGNANCY CONFIRMATION
Your above named employee / employee’s spouse/partner is pregnant and presently under my
care.
Date of expected delivery:

____________________________________

Last day medically able to work before delivery:

____________________________________

(If different