Lactation Accommodation Request Form

Form for employees to request lactation accommodations, including schedule needs, private space requirements, frequency of breaks, and any supplies or support needed.

Employee Information

• Employee Name
• Employee ID
  Optional if your organization uses employee IDs for HR routing.
• Department
• Work Location
• Preferred Contact Method
• Preferred Contact Details
  Enter the email address or phone number where HR can reach you.

Accommodation Request

• What do you need help with?
• When do you need this accommodation to start?
• When do you expect to stop needing this accommodation?
  Optional if the end date is not known.
• How soon do you need this accommodation?
• Additional Details
  Share only the details needed to coordinate the accommodation.

Schedule and Break Needs

• How many lactation breaks do you typically need per day?
• Typical length of each break (minutes)
• Preferred Break Times
  Example: mid-morning, lunch, and mid-afternoon.
• How flexible is your schedule for break timing?

Private Space, Storage, and Supplies

• What features do you need in a private space?
• Do you need storage for expressed milk?
• Storage Details
• Supplies or support needed
• Other Support Details

Confidentiality and Consent

• I understand this request will be handled confidentially and shared only with people who need it to process my accommodation.
• I consent to HR contacting me about this request using the preferred contact method provided.
• Employee Signature
• Submission Date