Lactation Accommodation Request Form
A lactation accommodation request form for employees to request break timing, private space, storage, and supplies. Use it to collect only the details HR needs to arrange support and follow up.
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Overview
This lactation accommodation request form helps employees ask for the practical support they need to express milk at work: break timing, expected duration, preferred times, private space needs, storage, and supplies. It is built for HR intake, not for medical documentation, so the fields stay focused on scheduling and workplace setup.
Use this template when an employee needs a new accommodation, when their schedule changes, or when they move to a different work location. The structure supports progressive disclosure: the employee can describe the request type first, then add only the details that apply. That makes it easier to route the request to HR, a manager, or facilities without exposing unnecessary PII.
Do not use this form as a general wellness survey or as a substitute for a broader leave process. It is also not the right place to collect diagnosis details, infant information, or other data you do not need to act on the request. If your workplace already has a separate accommodations workflow, this form should feed into that process and create a clear record of what was requested, who reviewed it, and what happens next.
Standards & compliance context
- Limit collection to the minimum necessary information needed to process the accommodation request, consistent with data minimization principles.
- Use a confidentiality notice and consent language to explain how employee PII will be handled and who may see it.
- Design the form for accessibility with clear labels, keyboard-friendly controls, and readable validation messages to support WCAG 2.1 AA use.
- If the form is used in an HR intake workflow, avoid collecting unrelated health details and keep the process aligned with reasonable-accommodation handling.
General regulatory context for orientation only — verify current requirements with counsel or the relevant agency before relying on this template for compliance.
What's inside this template
Employee Information
This section identifies the employee and their work context so the request can be routed correctly without collecting unnecessary details.
- Employee Name
- Work Email
- Department
- Work Location
Accommodation Request
This section captures the core request type and timing so HR can understand what support is needed and when it should start.
- 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
This section translates the request into actionable scheduling details that managers can use to plan coverage.
- 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
This section defines the physical setup needed so facilities or site leads can prepare the right space and materials.
- 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
This section explains how the information will be handled and confirms the employee understands the review process.
- 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?
How to use this template
- Add the employee information fields, the accommodation request section, and the confidentiality notice, then remove any field you do not need to make a decision.
- Set required fields only for the minimum information needed to route the request, and use a date picker, numeric input, and multi-select where the data type calls for it.
- Assign the form to HR or the designated accommodations owner, and configure conditional logic so private space, storage, and supply questions appear only when relevant.
- Review the submitted schedule, space, and supply needs, then coordinate with the manager, facilities, or site lead to confirm what can be provided and when.
- Send a clear follow-up message that states the next step, who will respond, and what the employee should do if their schedule or location changes.
Best practices
- Keep the form focused on logistics and avoid asking for medical details, infant information, or any PII you do not need to arrange the accommodation.
- Use conditional logic so employees only see private space, storage, and supply fields when those needs apply.
- Mark required versus optional fields clearly and keep the required set as small as possible.
- Use a date picker for start date and a numeric input for break duration so the form is easier to complete and validate.
- Include a plain-language confidentiality notice and a consent field that explains how the request will be reviewed and shared internally.
- Specify what happens after submission, including who reviews the request and how the employee will be contacted.
- If multiple locations are involved, ask for the work location first so routing and space planning are accurate.
- Avoid open-ended schedule questions when a few structured time options would make approval and staffing easier.
What this template typically catches
Issues teams running this template most often surface in practice:
Common use cases
Frequently asked questions
Who should use this lactation accommodation request form?
Use it for employees who need time, space, or supplies to express milk at work. It is typically completed by the employee and reviewed by HR, a manager, or a designated accommodations contact. The form is designed to capture only the details needed to arrange the accommodation and follow up.
What information does this template collect?
It collects employee contact details, the type of accommodation requested, timing and duration needs, private space requirements, storage needs, and any supplies needed. It also includes confidentiality and consent language so the employee understands how the information will be used. Keep the fields focused on logistics, not medical history.
How often should this form be submitted?
Use it when a new lactation accommodation is needed, when the employee’s schedule changes, or when space and supply needs change. Some organizations also use it for periodic review if the arrangement is temporary or if work location changes. The form is not meant for daily check-ins.
Is this form only for HR, or can managers handle it too?
HR usually owns the intake and recordkeeping, while managers may only need the minimum information required to adjust schedules. If your process routes requests to facilities or operations, use conditional logic or internal routing to limit who sees PII. That keeps the process aligned with confidentiality expectations.
How does this template support privacy and confidentiality?
The template includes a confidentiality notice and a consent field so the employee knows how their information will be processed. It also helps you avoid collecting unnecessary PII by focusing on accommodation logistics rather than personal or medical details. If you allow anonymous submission for general feedback, keep this form separate because accommodation requests usually need follow-up contact.
What are the most common mistakes when using this form?
Common mistakes include making every field required, asking for too much personal detail, and using free-text fields where a date picker or numeric input would be clearer. Another issue is failing to define what happens after submission, which leaves employees unsure about next steps. A good template should make the review path and response timing clear.
Can this template be customized for different workplaces?
Yes. You can adjust the private space section for office, retail, warehouse, or field-based work, and you can tailor the supply list to what your site actually provides. You can also add conditional logic for remote workers, multiple locations, or shared facilities. Keep the form short and only add fields that change the accommodation decision.
How does this compare with handling requests by email or chat?
Email and chat are easy to start but hard to standardize, track, and secure. A form gives you consistent fields, a clearer audit trail, and fewer back-and-forth messages about missing details. It also helps HR apply the same process across employees without relying on informal notes.
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