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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 collect only the details HR nee...

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Employee Information

Employee Name (required)

Work Email (required)

Department (required)

Work Location (required)

Accommodation Request

What do you need? (required)

Describe your request (required)

Briefly describe the accommodation you are requesting and any constraints HR should know about.

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

How long do you expect to need this accommodation?

Schedule and Break Needs

How often do you expect to need breaks? (required)

Typical break length (minutes) (required)

Preferred times of day

Any schedule constraints or notes?

Private Space, Storage, and Supplies

Do you need a private space? (required)

What should the private space include?

Do you need milk storage or refrigeration access? (required)

What supplies or equipment support do you need?

Additional space or supply notes

Confidentiality and Consent

Confidentiality notice

I consent to HR using the information I provide to review and coordinate my lactation accommodation request. (required)

Yes No N/A

Preferred contact method (required)

Anything else HR should know?

Get your results

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Email (required)

Your name (optional)

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