Short note to your employer
A printable from Time Off After Pregnancy Loss. Fill it in by hand. Nothing you write is collected by this website.
Short note to your employer
Date: ______________ To: ______________
I am taking reproductive loss leave under California Government Code section 12945.6.
Days I will be off: ______________ I would like to use: sick days / vacation / unpaid leave (circle one)
Please keep this request confidential.
Thank you, Name: ______________
Keep a copy. Write down who you sent it to and when.
From Time Off After Pregnancy Loss. Facts checked October 21, 2026. Free information, not legal or medical advice.