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Run: Lactation Accommodation Request Form

A Lactation Accommodation Request Form for employees to request break timing, private space, storage, and supplies. Use it to document needs clearly, protect...

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Employee Information

Employee Name (required)

Employee ID

Optional if your organization uses employee IDs for HR routing.

Department (required)

Work Location (required)

Preferred Contact Method (required)

Preferred Contact Details (required)

Enter the email address or phone number where HR can reach you.

Accommodation Request

What do you need help with? (required)

When do you need this accommodation to start? (required)

When do you expect to stop needing this accommodation?

Optional if the end date is not known.

How soon do you need this accommodation? (required)

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? (required)

Typical length of each break (minutes) (required)

Preferred Break Times

Example: mid-morning, lunch, and mid-afternoon.

How flexible is your schedule for break timing? (required)

Private Space, Storage, and Supplies

What features do you need in a private space? (required)

Do you need storage for expressed milk? (required)

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. (required)

Yes No N/A

I consent to HR contacting me about this request using the preferred contact method provided. (required)

Yes No N/A

Employee Signature (required)

Submission Date (required)

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Email (required)

Your name (optional)

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