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Run: Pregnancy Accommodation Request Form

Use this Pregnancy Accommodation Request Form to document pregnancy-, childbirth-, or related-condition accommodation needs, requested changes, and follow-up...

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Employee Information

Employee Name (required)

Employee ID

Work Location (required)

Department (required)

Job Title (required)

Preferred Contact Email (required)

Accommodation Request

Reason for Request (required)

Work Limitations or Symptoms Affecting Your Job (required)

Select all that apply. Only include limitations relevant to your work duties.

Other Limitation Details

Requested Accommodations (required)

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

Requested Start Date (required)

Requested End Date

Is this a temporary request? (required)

How soon do you need this accommodation? (required)

Supporting Information

Supporting Documentation

Optional medical note or other supporting documentation, if available.

Can you provide supporting documentation if requested? (required)

Consent to Review Supporting Information (required)

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.

Yes No N/A

Interactive Process and Follow-Up

Preferred Meeting Format (required)

Communication or Accessibility Needs

Share any reasonable communication or accessibility needs for the review process.

Additional Comments

Employee Acknowledgment (required)

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.

Yes No N/A

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Email (required)

Your name (optional)

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