Pregnancy Accommodation Request Form
Use this Pregnancy Accommodation Request Form to document pregnancy, childbirth, or related medical-condition accommodation needs, the job functions affected, and the employee’s preferred options in one place.
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Overview
This Pregnancy Accommodation Request Form captures the information HR needs to start and document a pregnancy-related accommodation request: employee details, the accommodation being requested, the job functions affected, timing, preferred and alternative accommodations, supporting documentation, and consent for any medical information shared.
Use it when an employee needs a workplace adjustment tied to pregnancy, childbirth, or a related medical condition and you want a consistent intake process instead of scattered emails. The form is especially useful when the request may involve schedule changes, breaks, temporary task changes, seating, equipment, or workspace modifications. It also helps the employee describe what is difficult about the current setup and what alternatives might work.
Do not use this form to gather broad medical history or unrelated personal data. If the request is simple and can be handled without documentation, keep the supporting information section minimal. If your process already has a separate leave form, this template should stay focused on accommodation intake, not leave administration. The best version of this form uses clear required vs optional fields, conditional logic for role-specific needs, and a plain-language note explaining what happens after submission.
Standards & compliance context
- Structure the form to support the PWFA interactive process by documenting the request, the affected job functions, and the accommodation options under review.
- Apply GDPR Article 5 data minimization by collecting only the PII and medical information needed to evaluate the accommodation request.
- If the form is public-facing or employee-facing in a portal, follow WCAG 2.1 AA practices such as clear labels, keyboard access, and readable validation messages.
- Treat any medical details as sensitive information with restricted access, an audit trail where available, and a clear disclosure of who can view the submission.
- If your policy allows it, offer an anonymous or limited-disclosure path for initial intake only where it still supports follow-up and does not block the accommodation process.
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 the right manager or HR contact so the request can be routed without delay.
- Employee name
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Employee ID
Optional if your organization uses an employee ID for routing requests.
- Work email
- Work phone
- Department
- Job title
- Manager name
Accommodation Request
This section captures what the employee needs and which job functions are affected, which is the core of the interactive process.
- What type of accommodation are you requesting?
-
Briefly describe the accommodation you need
Describe the workplace change you are requesting. Do not include unnecessary medical details.
-
Which job duties are affected?
Select any duties that are difficult to perform without accommodation.
-
When do you need this accommodation to start?
If the need is immediate, HR may contact you sooner to discuss temporary options.
Timing and Duration
This section helps HR understand whether the accommodation is temporary, ongoing, or tied to a known date range.
- Requested start date
-
Requested end date
Leave blank if you do not know the end date.
- Do you know how long you will need the accommodation?
- If known, describe the expected duration
Work Impact and Alternatives
This section documents how the current setup is creating difficulty and what other accommodations may work instead.
-
How does your current work situation affect you?
Share only the minimum information needed to understand the work impact.
- Which accommodations would you prefer?
- Are there alternative accommodations that would also work?
-
Do you need any equipment or workspace changes?
Examples: chair, stool, closer parking, adjusted workstation height.
Supporting Information
This section controls any documentation and consent so the form stays privacy-aware and limited to minimum necessary data.
-
Upload supporting documentation
Optional. Attach any documentation you want HR to review.
- I understand that any medical or PII information I provide will be used only to review this accommodation request and will be handled confidentially where permitted by law.
- I consent to HR contacting me about this request using the contact information provided above.
Employee Certification and Submission
This section confirms the employee’s submission, creates a record of accuracy, and gives HR a place to log follow-up actions.
- I certify that the information provided is accurate to the best of my knowledge.
- Employee signature
- Submission date
- HR follow-up notes
How to use this template
- 1. Add your organization’s HR contact, accommodation workflow, and privacy notice so the employee knows who will review the request and what happens after submission.
- 2. Configure the employee information and request fields with clear required vs optional labels, using conditional logic to show only the job-impact questions that apply.
- 3. Ask the employee to describe the accommodation request, the essential job functions affected, the timing, and any preferred or alternative accommodations in specific terms.
- 4. Review any supporting documentation and consent fields, limiting collection to the minimum necessary and confirming whether medical information is actually needed.
- 5. Route the completed form to HR or the accommodation coordinator for review, then record follow-up notes, approved adjustments, and any next-step communication.
- 6. Close the loop by documenting the outcome, start and end dates if applicable, and any changes if the employee’s needs evolve over time.
Best practices
- Use a date picker for start and end dates, and avoid free-text date fields that create validation errors and inconsistent records.
- Mark only the fields you truly need as required, and keep the form short enough that employees can complete it without unnecessary friction.
- Use progressive disclosure so equipment, workspace, lifting, travel, or shift questions appear only when the request type makes them relevant.
- Explain in plain language what happens after submission, including who reviews the form and whether the employee may be contacted for clarification.
- Limit supporting documentation requests to the minimum necessary and state clearly whether medical information is optional, required, or reviewed separately.
- Include a contact consent field only if HR may need to follow up by phone or email, and make the purpose of that consent explicit.
- Capture alternative accommodations, not just the preferred one, so HR can evaluate workable options without restarting the intake process.
- Keep the employee certification concise and specific to the accuracy of the request, not a broad waiver or unrelated acknowledgment.
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 Pregnancy Accommodation Request Form?
Use it when an employee needs a workplace accommodation related to pregnancy, childbirth, or a related medical condition. It is typically completed by the employee and reviewed by HR or the designated accommodation contact. Managers may help route the form, but they should not collect more medical detail than necessary. The form is designed to start the interactive process with a clear record of the request.
What kinds of requests does this template cover?
It covers common workplace adjustments such as schedule changes, more frequent breaks, temporary reassignment of certain tasks, seating changes, or equipment and workspace changes. The request section captures what is needed and which essential job functions are affected. It also leaves room for alternative accommodations if the preferred option is not workable. That makes it useful for both simple and more complex requests.
How often is this form used?
It is usually used whenever an employee first requests an accommodation and again if the need changes over time. The timing and duration section helps HR track whether the request is short-term, ongoing, or tied to a known end date. If the employee’s condition or work restrictions change, a revised form or follow-up note can be added. That keeps the record current without overcollecting information.
Who should review and approve the request?
HR, leave administrators, or the accommodation coordinator should review the form, often with input from the employee’s manager on job duties and operational impact. Medical details should be limited to what is needed to evaluate the request, consistent with data minimization. The manager should focus on essential functions and feasible alternatives, not diagnosis. Final approval should be documented in the follow-up notes or an audit trail.
Does this form have a regulatory or compliance angle?
Yes. It is built for pregnancy-related accommodation requests under the PWFA and should also be handled with privacy and accessibility in mind. Any public-facing or employee-facing version should meet WCAG 2.1 AA expectations, including clear labels, keyboard access, and readable validation messages. If medical information is collected, the form should explain why it is needed and who can access it. Keep the collection limited to the minimum necessary.
What are the most common mistakes when using this form?
Common mistakes include making every field required, asking for diagnosis details that are not needed, and skipping the section on alternative accommodations. Another frequent issue is using free-text fields where a date picker, multi-select, or yes/no choice would be clearer. Teams also sometimes forget to tell the employee what happens after submission. This template helps avoid those gaps by structuring the request and follow-up.
Can this form be customized for different roles or workplaces?
Yes. You can tailor the job-function section to match office, retail, healthcare, manufacturing, or field roles. Conditional logic can show equipment, lifting, standing, travel, or shift-related prompts only when relevant. You can also adjust the supporting documentation field to reflect your internal policy. The structure is flexible enough to fit different accommodation workflows without losing consistency.
How does this compare with handling requests by email or chat?
Email and chat can work for the first notice, but they often leave out key details like timing, essential functions, and preferred alternatives. This form creates a consistent record, supports an audit trail, and reduces back-and-forth. It also helps HR apply the same process across requests instead of relying on ad hoc notes. That makes review faster and easier to document.
What should employees know before submitting supporting documentation?
Employees should know whether documentation is optional or required under your policy and what type of information is actually needed. The form should explain any consent for medical information and who will see it. If the request can be evaluated without documentation, the form should not force unnecessary uploads. Clear disclosure language helps protect privacy and improves completion rates.
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