Pregnancy, Childbirth, or Lactation Accommodation Request Form

ADA & Accommodations

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Note to Employers: Requests for reasonable accommodation can be made in face-to-face conversations or using any other method of communication. However, it is recommended that employers ask for requests in writing so there is documentation in case of a dispute about whether or when an accommodation request was made.

Employee Instructions: Complete this form to request accommodation for pregnancy, childbirth, or related medical conditions. Return the completed form to [insert person, position, or department]. Except as otherwise noted below, the Company has the right to request medical information, if necessary, when an employee requests accommodation. If documentation is not provided, your request may be delayed or denied. We will review and respond to your request promptly.

Young Pregnant Woman