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Run: Pregnancy Accommodation Request Form

Use this Pregnancy Accommodation Request Form to document pregnancy, childbirth, or related medical-condition accommodation needs, the job functions affected...

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Employee Information

Employee name (required)

Employee ID

Optional if your organization uses an employee ID for routing requests.

Work email (required)

Work phone

Department (required)

Job title (required)

Manager name

Accommodation Request

What type of accommodation are you requesting? (required)

Briefly describe the accommodation you need (required)

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

Requested start date (required)

Requested end date

Leave blank if you do not know the end date.

Do you know how long you will need the accommodation? (required)

If known, describe the expected duration

Work Impact and Alternatives

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

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. (required)

Yes No N/A

I consent to HR contacting me about this request using the contact information provided above. (required)

Yes No N/A

Employee Certification and Submission

I certify that the information provided is accurate to the best of my knowledge. (required)

Yes No N/A

Employee signature (required)

Submission date (required)

HR follow-up notes

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Email (required)

Your name (optional)

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