Pregnancy Accommodation Request Form

Form for employees to request workplace accommodations related to pregnancy, childbirth, or related medical conditions under the PWFA.

Employee Information

• Employee name
• Employee ID
  Optional if your organization uses an employee ID for routing requests.
• Work email
• Work phone
• Department
• Job title
• Manager name

Accommodation Request

• What type of accommodation are you requesting?
• Briefly describe the accommodation you need
  Describe the workplace change you are requesting. Do not include unnecessary medical details.
• Which job duties are affected?
  Select any duties that are difficult to perform without accommodation.
• When do you need this accommodation to start?
  If the need is immediate, HR may contact you sooner to discuss temporary options.

Timing and Duration

• Requested start date
• Requested end date
  Leave blank if you do not know the end date.
• Do you know how long you will need the accommodation?
• If known, describe the expected duration

Work Impact and Alternatives

• How does your current work situation affect you?
  Share only the minimum information needed to understand the work impact.
• Which accommodations would you prefer?
• Are there alternative accommodations that would also work?
• Do you need any equipment or workspace changes?
  Examples: chair, stool, closer parking, adjusted workstation height.

Supporting Information

• Upload supporting documentation
  Optional. Attach any documentation you want HR to review.
• I understand that any medical or PII information I provide will be used only to review this accommodation request and will be handled confidentially where permitted by law.
• I consent to HR contacting me about this request using the contact information provided above.

Employee Certification and Submission

• I certify that the information provided is accurate to the best of my knowledge.
• Employee signature
• Submission date
• HR follow-up notes