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Run: 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...

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Employee Information

Full Name (required)

Employee ID

Job Title (required)

Department (required)

Work Location

Manager Name

Accommodation Request

Request Date (required)

Requested Accommodation Type (required)

Describe the Accommodation Needed (required)

Job Duties Affected

Impact on Essential Job Functions

Duration and Timing

Requested Start Date (required)

Requested End Date

Is the expected duration known? (required)

Duration Details

Will you notify HR if your needs change?

Yes No N/A

Medical or Supporting Information

Are you providing medical or other supporting documentation? (required)

Supporting Information

May HR contact your healthcare provider for clarification if needed?

Upload Supporting Documentation

Interactive Process and Follow-Up

Preferred Contact Method (required)

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. (required)

Yes No N/A

Get your results

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Email (required)

Your name (optional)

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