Pregnancy Accommodation Request Form
Use this Pregnancy Accommodation Request Form to document pregnancy-, childbirth-, or related-condition accommodation needs, requested changes, and follow-up details in one place. It helps HR start the interactive process with clear fields, consent language, and a record of what happens next.
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Overview
This Pregnancy Accommodation Request Form template is built for employees who need workplace changes related to pregnancy, childbirth, or related medical conditions. It captures the employee’s information, the reason for the request, the work limitations involved, the accommodations being requested, the expected duration, and any supporting information needed to review the request.
Use it when an employee needs a temporary or ongoing adjustment such as schedule changes, seating, lifting limits, break flexibility, remote work consideration, or task reassignment. The template is also useful when HR needs a consistent record to start the interactive process, coordinate a follow-up meeting, and document what was requested and what was agreed to.
Do not use this form to collect broad medical history, diagnosis details that are not needed, or unrelated leave information. If the employee only needs a simple scheduling note with no accommodation review, a lighter intake may be enough. The form is also not a substitute for a leave request form, though it can be used alongside one when both accommodation and leave issues are involved. The structure is designed to minimize PII, support accessibility, and keep the request focused on the employee’s actual work limitations and needed adjustments.
Standards & compliance context
- This template supports the PWFA by documenting pregnancy-related accommodation requests and helping HR begin the interactive process.
- The form should follow GDPR data minimization by collecting only the PII and medical details needed to evaluate the request.
- If you collect any health-related information, limit access to the minimum necessary reviewers and keep consent language clear.
- Design the form to meet WCAG 2.1 AA accessibility expectations, including clear labels, keyboard navigation, and accessible validation messages.
- If the form is used in an HR intake context, include reasonable-accommodation prompts for communication access needs and alternate submission methods.
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 work context so HR can route the request to the right manager, location, and case owner.
- Employee Name
- Employee ID
- Work Location
- Department
- Job Title
- Preferred Contact Email
Accommodation Request
This section captures the actual limitation and the specific changes the employee is asking for, which is the core of the interactive process.
- Reason for Request
-
Work Limitations or Symptoms Affecting Your Job
Select all that apply. Only include limitations relevant to your work duties.
- Other Limitation Details
-
Requested Accommodations
List one or more accommodations you would like us to consider.
-
Essential Job Functions Affected
Briefly describe any essential job functions that are affected by the limitation.
Duration and Timing
This section helps HR understand whether the need is temporary, when it starts, and whether the request needs immediate attention.
- Requested Start Date
- Requested End Date
- Is this a temporary request?
- How soon do you need this accommodation?
Supporting Information
This section controls whether documentation is needed and keeps any medical detail collection tied to consent and necessity.
-
Supporting Documentation
Optional medical note or other supporting documentation, if available.
- Can you provide supporting documentation if requested?
-
Consent to Review Supporting Information
I understand that any medical or supporting information I provide will be used only for evaluating this accommodation request and shared only with personnel involved in the process.
Interactive Process and Follow-Up
This section turns the intake into action by capturing meeting preferences, communication needs, and acknowledgment of next steps.
- Preferred Meeting Format
-
Communication or Accessibility Needs
Share any reasonable communication or accessibility needs for the review process.
- Additional Comments
-
Employee Acknowledgment
I certify that the information provided is accurate to the best of my knowledge and understand that HR may contact me for clarification or additional information.
How to use this template
- 1. Add the form to your HR intake workflow and mark each field as required or optional based on what you truly need to evaluate the request.
- 2. Route the employee through the Employee Information and Accommodation Request sections first so HR can identify the request, the location, and the job duties involved.
- 3. Use the Duration and Timing section to capture whether the need is temporary, when it starts, when it may end, and whether the request needs urgent review.
- 4. Ask for Supporting Information only when necessary, and include a consent field before collecting any medical details or documentation.
- 5. Review the Interactive Process and Follow-Up section to schedule a meeting, note communication access needs, and confirm the employee acknowledgment before closing the intake.
Best practices
- Keep the request focused on work limitations and needed adjustments, not on diagnosis details that are not necessary to decide the accommodation.
- Use conditional logic so supporting documentation fields appear only when HR actually needs them.
- Make date fields date pickers, not free-text boxes, and use multi-select fields for accommodations that may include more than one option.
- Mark optional fields clearly and avoid making every field required, especially for employees who may need a fast, low-friction submission path.
- Include a clear line that explains what happens after submission, who will review the request, and when the employee can expect follow-up.
- Offer an accessible contact method and meeting format so employees can request help completing the form or joining the interactive process.
- Limit access to sensitive fields and keep an audit trail of who reviewed, changed, or approved the request.
What this template typically catches
Issues teams running this template most often surface in practice:
Common use cases
Frequently asked questions
What is this form used for?
This form is used when an employee needs a workplace accommodation related to pregnancy, childbirth, or a related medical condition. It captures the request reason, limitations, requested accommodations, and timing so HR can begin the interactive process. It is designed to document only the information needed to evaluate and implement the request.
Who should complete the form?
The employee usually completes the form, with HR or a manager helping if the employee needs assistance. In some workplaces, a supervisor may route the form to HR after the employee submits it. The form should be easy to complete with clear required versus optional fields and an accessible layout.
When should an employee submit a pregnancy accommodation request?
The form should be submitted as soon as the employee knows a change is needed, especially if the accommodation affects scheduling, lifting, standing, travel, or access to breaks. It can also be used for temporary needs that change over time. The urgency field helps HR prioritize time-sensitive requests without forcing the employee to overexplain.
Does this form require medical details?
No, it should only collect medical details if they are necessary to evaluate the request and only with consent. The template includes a medical_details_consent field and a documentation_available option so the employee can indicate whether supporting documentation exists without oversharing. This supports data minimization and reduces unnecessary PII collection.
What accommodations can be requested with this form?
The form can capture common requests such as modified schedules, more frequent breaks, seating, lifting restrictions, temporary reassignment of certain tasks, or changes to work location. The requested_accommodations and essential_job_functions_affected fields help HR understand both the need and the job impact. You can customize the field options to match your workplace policies and roles.
How does this form support the interactive process?
It gives HR a structured record of the employee’s request, limitations, preferred meeting format, and communication access needs. That makes it easier to schedule a follow-up, discuss alternatives, and document the outcome. The employee_acknowledgment field also helps confirm that the employee understands the next steps.
What are the most common mistakes when using this form?
Common mistakes include making every field required, asking for unnecessary diagnosis details, and skipping a clear note about what happens after submission. Another issue is using free-text fields where a date picker, checkbox, or multi-select would be more accessible and easier to review. The form should also avoid collecting more PII than needed for the accommodation decision.
Can this form be integrated with HR workflows?
Yes, it can be routed into HR case management, ticketing, or document storage workflows after submission. Many teams connect it to notifications for HR, leave administration, or the employee’s manager, while keeping access limited to people who need the information. If you use integrations, preserve the audit trail and restrict sensitive fields.
How is this different from an ad-hoc email request?
An email thread can miss key details, create inconsistent records, and make follow-up harder. This template standardizes the fields needed to assess the request, supports accessibility, and gives HR a cleaner audit trail. It also reduces back-and-forth by prompting for timing, limitations, and preferred communication format up front.
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