Republika ng Pilipinas

Lalawigan ng Laguna
Pamahalaang Bayan ng KALAYAAN
Real St., San Juan, Kalayaan, Laguna
Telefax (049) 501-7771/Tel.no. (049) 572 – 4011

NOTICE FOR USE OF LACTATION FACILITIES

Name of Employee: ________________________________________________________________

Position/Department: ______________________________ Employee No. ____________________
Date of Birth: ____________________________________ Type of Delivery: __________________
Maternity Leave Date: _____________________________ End: ____________________________
Date back/returned to work: ________________________

I confirmed that I will be breastfeeding my child and I intend to avail of the allowance break time and
the use of the hospital lactation facilities in compliance to REPUBLIC ACT 10028 “EXPANDED
BREASTFEEDING PROMOTION ACT OF 2009” (Sec. 12. Lactation Periods. Nursing employees
shall be granted break intervals in addition to the regular time-off meals to breastfeed of express milk.
“Such intervals shall not be less than a total of forty (40) minutes for every eight (8) – hour working
period).

Date and time of availment: _____________________________________

I hereby declare that the information given above is true and correct. I agree that when I stop
breastfeeding I will notify the management and its representative accordingly for proper
documentation.

____________________________ _________________
Nursing/Lactating Employee Date
(Signature over Printed Name)

Noted by:

____________________________ _________________
Signature over Printed Name Date
Department Head

Acknowledged by:

____________________________
Patient Care Service Director