Lactation Accommodation Request Form

Form for employees to request lactation accommodations, including schedule needs, private space, frequency of use, and required supplies.

Employee Information

• Employee Name
• Work Email
• Department
• Work Location

Accommodation Request

• What do you need?
• Describe your request
  Briefly describe the accommodation you are requesting and any constraints HR should know about.
• When do you need this accommodation to start?
• How long do you expect to need this accommodation?

Schedule and Break Needs

• How often do you expect to need breaks?
• Typical break length (minutes)
• Preferred times of day
• Any schedule constraints or notes?

Private Space, Storage, and Supplies

• Do you need a private space?
• What should the private space include?
• Do you need milk storage or refrigeration access?
• What supplies or equipment support do you need?
• Additional space or supply notes

Confidentiality and Consent

• Confidentiality notice
• I consent to HR using the information I provide to review and coordinate my lactation accommodation request.
• Preferred contact method
• Anything else HR should know?