Pregnancy Accommodation Request Form
Help employees request pregnancy-related accommodations clearly and quickly, while giving HR the details needed to start the interactive process and document next steps.
Trusted by frontline teams 15 years of frontline software AI customization in seconds
Built for: Healthcare · Manufacturing · Retail · Office And Professional Services · Logistics
Overview
The Pregnancy Accommodation Request Form gives HR a structured way to capture requests tied to pregnancy, childbirth, or related medical conditions. It collects employee details, the accommodation being requested, the duties affected, expected timing, supporting information, and the preferred way to continue the conversation. That makes it easier to start the interactive process, route the request to the right owner, and keep a clear record of what was asked for and when.
Use this template when an employee needs a change to how work is performed, such as modified lifting, more frequent breaks, schedule changes, seating, access to water, or temporary duty adjustments. It is especially useful when the request may last for a limited period or needs review as the pregnancy progresses. The form also helps when multiple people need to coordinate, such as HR, a manager, and a leave specialist.
Do not use this form as a substitute for a medical exam, a broad medical history intake, or a disciplinary document. It is not meant for unrelated disability accommodation requests, performance issues, or leave administration by itself. If your process requires more detailed review, this form should be the starting point, not the final decision record.
Standards & compliance context
- This form supports documentation of pregnancy-related accommodation requests under the Pregnant Workers Fairness Act.
- Limit medical questions to information needed to evaluate the accommodation and avoid requesting unnecessary diagnosis details.
- Store supporting documents and provider contact information in a restricted HR file with access limited to people who need it.
- Use the form as part of an interactive process rather than a one-step approval or denial workflow.
- Review the template with counsel or your compliance team if your state or local law provides additional pregnancy accommodation requirements.
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 workplace context so HR can route the request to the right manager and case owner.
- Full Name
- Employee ID
- Job Title
- Department
- Work Location
- Manager Name
Accommodation Request
This section captures what the employee needs and how the request affects the job, which is the core of the interactive process.
- Request Date
- Requested Accommodation Type
- Describe the Accommodation Needed
- Job Duties Affected
- Impact on Essential Job Functions
Duration and Timing
This section helps HR understand whether the accommodation is temporary, when it should start, and when it may need review.
- Requested Start Date
- Requested End Date
- Is the expected duration known?
- Duration Details
- Will you notify HR if your needs change?
Medical or Supporting Information
This section records whether documentation is provided and keeps any supporting materials tied to the request without over-collecting medical detail.
- Are you providing medical or other supporting documentation?
- Supporting Information
- May HR contact your healthcare provider for clarification if needed?
- Upload Supporting Documentation
Interactive Process and Follow-Up
This section sets the communication path so HR can follow up efficiently and document the employee’s consent to discuss the request.
- Preferred Contact Method
- Best Time to Contact You
- Additional Notes for the Interactive Process
- I consent to HR discussing this request with my manager as needed to evaluate and implement accommodations.
How to use this template
- 1. Add your company’s HR contact, submission method, and any internal case number fields before publishing the form.
- 2. Ask the employee to describe the accommodation requested, the duties affected, and any timing details in plain language.
- 3. Route the submission to HR or the accommodations owner so the interactive process can begin promptly.
- 4. Review the supporting information, confirm what is needed to evaluate the request, and document follow-up questions separately.
- 5. Record the agreed accommodation, the expected duration, and any change-notification instructions in the case file.
- 6. Revisit the request if the employee’s needs, schedule, or work restrictions change.
Best practices
- Use plain language for accommodation options so employees can describe what they need without knowing legal terms.
- Capture the essential job functions affected, not just the symptom or diagnosis, so HR can evaluate the request against actual work duties.
- Keep medical details limited to what is needed for the accommodation review and store supporting documents in a restricted location.
- Ask for the expected duration and a change-notification plan so temporary accommodations do not expire unnoticed.
- Give employees a direct contact method for follow-up so questions do not stall in a general inbox.
- Separate the intake form from the decision record so the request, review, and outcome stay easy to audit.
- Train managers to forward requests to HR immediately instead of trying to resolve them informally.
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 helps an employee request a workplace accommodation related to pregnancy, childbirth, or a related medical condition. It captures the request, the work duties affected, timing, and any supporting information HR may need. That makes it easier to start the interactive process without back-and-forth. It also creates a clear record of what was requested and when.
How often should employees submit this form?
Employees should submit it whenever they need a new accommodation or when an existing accommodation needs to change. It can also be used if symptoms, restrictions, or job duties change during pregnancy. Some requests are one-time adjustments, while others may need updates over time. The form is designed to support both situations.
Who should run the process after the form is submitted?
HR usually owns the intake and follow-up, often in coordination with the employee’s manager and, when needed, a leave or benefits specialist. The manager should not handle medical details beyond what is necessary to implement the accommodation. HR should keep the process consistent and document decisions carefully. If your company has an ADA or accommodations lead, that person may also be involved.
Does this form have a compliance angle?
Yes. It is meant to support accommodation requests under the Pregnant Workers Fairness Act and related workplace obligations. The form helps document the request, the interactive process, and any supporting information without asking for more medical detail than needed. It should be used alongside your company’s legal review and accommodation procedures. It is not a substitute for legal advice.
What are common mistakes when using this form?
A common mistake is asking for unnecessary medical information or treating every request as if it needs the same level of documentation. Another is failing to capture how long the accommodation is expected to last or how the employee should report changes. Some teams also forget to document follow-up conversations and decisions. Those gaps can make implementation inconsistent and harder to track.
Can this form be customized for different roles or locations?
Yes. You can tailor the accommodation options, add location-specific contact fields, or include role-specific duty examples. For example, a warehouse team may need lifting or standing adjustments, while an office team may need schedule or seating changes. You can also adjust the supporting information section to match your internal documentation standards. Keep the core request and follow-up fields intact.
What systems should this form connect to?
It often works well with HRIS, case management, document storage, and ticketing or workflow tools. Integrations can route the request to HR, notify the manager, and store supporting documents in the right case file. If your company uses an accommodations platform, this form can serve as the intake layer. The goal is to reduce manual handoffs and preserve a clean record.
How does this compare with handling requests by email or chat?
Ad hoc requests are easy to miss, hard to compare, and often leave out key details like timing or preferred contact method. A form creates a consistent intake path and makes it easier to start the interactive process quickly. It also helps HR avoid repeated questions and keeps sensitive information in one controlled place. That usually leads to faster, clearer follow-up.
Related templates
Ready to use this template?
Get started with MangoApps and use Pregnancy Accommodation Request Form with your team — pricing built for small business.
