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Run: Lactation Accommodation Request Form

Capture lactation accommodation requests in one place so HR can arrange private space, break timing, and any needed supplies without back-and-forth.

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Employee Information

Employee Name (required)

Employee ID

Department (required)

Job Title

Work Location (required)

Supervisor Name

Accommodation Needs

Type of Request (required)

Requested Start Date (required)

Expected Duration of Accommodation (required)

Additional Details

Schedule and Break Frequency

How often do you need lactation breaks? (required)

Typical Break Duration (required)

Preferred Break Times

How flexible is your schedule for coordinating breaks? (required)

Space, Storage, and Supplies

Space Requirements (required)

Storage Needs

Supplies Needed

Equipment or Setup Notes

Follow-Up and Confidentiality

Preferred Contact Method (required)

Best Time to Contact

Confidentiality or Privacy Requests

Get your results

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Email (required)

Your name (optional)

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