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
• Work Location
• Department
• Job Title
• Preferred Contact Email

Accommodation Request

• Reason for Request
• Work Limitations or Symptoms Affecting Your Job
  Select all that apply. Only include limitations relevant to your work duties.
• Other Limitation Details
• Requested Accommodations
  List one or more accommodations you would like us to consider.
• Essential Job Functions Affected
  Briefly describe any essential job functions that are affected by the limitation.

Duration and Timing

• Requested Start Date
• Requested End Date
• Is this a temporary request?
• How soon do you need this accommodation?

Supporting Information

• Supporting Documentation
  Optional medical note or other supporting documentation, if available.
• Can you provide supporting documentation if requested?
• Consent to Review Supporting Information
  I understand that any medical or supporting information I provide will be used only for evaluating this accommodation request and shared only with personnel involved in the process.

Interactive Process and Follow-Up

• Preferred Meeting Format
• Communication or Accessibility Needs
  Share any reasonable communication or accessibility needs for the review process.
• Additional Comments
• Employee Acknowledgment
  I certify that the information provided is accurate to the best of my knowledge and understand that HR may contact me for clarification or additional information.